Tuberculosis (TB) and Hepatitis B virus (HBV) infections are quite common in the developing world especially South Asia. As both are so common, co-infection is not very uncommonly encountered in clinical practice. However, since anti-tuberculosis therapy (ATT) can be hepatotoxic in around 10% of patients, the occurrence of hepatotoxicity can complicate management especially in the presence of already compromised liver function due to HBV. Therefore, co-infection of TB and HBV is an important public health issue. Unfortunately the regional and National hepatology societies of South Asia have not bothered to provide any guidance in this matter. This article reviews the epidemiology and management of co-infection with Tuberculosis (TB) and Hepatitis B virus (HBV) and the hepatotoxicity due to ATT.

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About two billion people worldwide have been infected with the hepatitis B virus and about 350 million live with chronic infection. Besides, an estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B. The course of HBV infection is a dynamic process and is influenced by many factors including viral, host, and exogenous factors. Clinical suspicion of acute viral hepatitis usually does not necessitate biopsy; however, persistence of clinical symptoms or biochemical evidence of hepatotrophic viral infection for more than six months duration necessitates a liver biopsy - in several instances to primarily establish the histopathological diagnosis, to grade and stage the hepatic changes (determine management and prognosis), to document the severity and extent of the hepatic inflammation, as a guide to therapy or to monitor the changes of liver histology while on treatment. Moreover, improvement in liver histology can be used as an endpoint in clinical trials for new forms of therapy. Additionally, in some cases there is considerable clinical overlap between the states of exacerbation of chronic hepatitis and acute hepatitis. Biopsy is helpful in these cases too. Nevertheless, it must be mentioned that with the current trends and various guidelines, the indications for liver biopsy in chronic hepatitis B are somewhat reduced. It is hoped that with non-invasive markers the number of liver biopsies will reduce further. This article provides an overview of the histopathology of chronic hepatitis B virus infection.

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Background and Aim: Hepatitis B virus (HBV)-related liver disease is not an uncommon problem in India. There are very few reports on pattern of chronic HBV infection from South India. The aim of the present study was to determine the spectrum of chronic HBV infection among patients attending the liver clinic in a tertiary referral center. Materials and Methods: Hepatitis B surface antigen (HBsAg) positive patients registered in the liver clinic between July 2010 and March 2011 were included in the study. All patients had baseline liver function tests, serological markers for HBV infection (hepatitis B e antigen [HBeAg], anti-HBe, anti-HBc total, and anti-HBc IgG, and HBV DNA quantification), serum alpha-fetoprotein, and ultrasound. Based on the viral profile and transaminase levels and ultrasound findings, patients were categorized as immunotolerant, inactive carriers, immune clearance and reactivation phase, and chronic liver disease with or without hepatocellular carcinoma. Results: Majority of the patients were asymptomatic and incidentally detected during blood donation camps, master health checkup (MHC), or during initial screening. Almost 40% of patients were either in immune inactive phase or had features of chronic liver disease. In the immunotolerant phase (24 patients), women were a decade younger than their male counterparts. Alanine aminotransferase (ALT) levels were similar in both HBeAg-positive and negative patients. The mean HBV DNA values were significantly high in HBeAg-positive men and women. In the immune inactive phase (58 patients), there were only three patients who were HBeAg positive. The ALT levels were in the normal range. HBV DNA values were low or not detectable. Among patients with elevated ALT and HBV DNA levels (immune clearance/immune reactive) (fifty patients), the mean ALT levels were higher in HBeAg-negative patients. HBV DNA quantity was significantly high in patients who were HBeAg positive. Conclusion: A significant proportion of HBsAg-positive patients is in inactive or in immunotolerant phase and do not require treatment. Patients with elevated ALT and HBV DNA levels need further evaluation to categorize them into immune clearance or immune reactive phase.

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Nonalcoholic fatty liver disease [NAFLD] has rapidly emerged as the most common liver disorder not only in developed countries, but also in the developing countries. This entity encompasses a wide variety of liver abnormalities ranging from plain hepatic steatosis through nonalcoholic steatohepatitis [NASH] to cirrhosis of the liver and hepatocellular carcinoma [HCC]. NAFLD is now recognized as the hepatic manifestation of insulin resistance [IR], and an important marker of the metabolic syndrome [MS]. Although a number of advances have been made in elucidating the pathogenetic mechanisms involved in the causation and perpetuation of NAFLD, a great many unanswered questions remain unresolved yet. In view of the involvement of so many different pathways in the pathogenesis, there has always been a speculation regarding the interaction between NAFLD and other liver diseases especially chronic hepatitis C [CHC] and chronic hepatitis B [CHB], because of theubiquitous distribution of NAFLD and its common association with other liver diseases.

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