inflammation in rat intestine. Gastroenterology 2002;123:1099–108.

12. Wilson LM, Baldwin AL. Environmental stress causes mastcell degranulation, endothelial and epithelial changes, andedema in the rat intestinal mucosa. Microcirculation 1999;6:189–98.

13. Gwee KA, Leong YL, Graham JC, et al. The role of psycho-logical and biological factors in post infective gut dysfunction.Gut 1999;44:400–6.

14. Bayless TM, Harris ML. Inflammatory bowel disease andirritable bowel syndrome. Med Clin North Am 1990;74:21–9.

15. Soderholm JD, Yates DA, Gareau MG, et al. Neonatal mater-nal separation predisposes adult rats to colonic barrier dys-function in response to mild stress. Am J Physiol GastrointestLiver Physiol 2002;283:G1257–63.

16. Maunder R, Lancee W, Greenberg G, et al. Insecure attach-ment in a subgroup of ulcerative colitis defined by ANCAstatus. Dig Dis Sci 2000;45:2127–32.

17. Sternberg EM, Hill JM, Chrousos GP, et al. Inflammatorymediator-induced hypothalamic-pituitary-adrenal axis activa-tion is defective in streptococcal cell wall arthritis- susceptibleLewis rats. Proc Natl Acad Sci U S A 1989;86:2374–8.

18. Sartor R. Current concepts of the etiology and pathogenesis ofulcerative colitis and Crohn’s disease. Gastroenterol ClinNorth Am 1995;24:475–507.

19. Saunders PR, Kosecka U, McKay DM, Perdue MH. Acutestressors stimulate ion secretion and increase epithelial perme-ability in rat intestine. Am J Physiol 1994;267(5 pt 1):G794–9.

20. Meddings JB, Swain MG. Environmental stress-induced gas-trointestinal permeability is mediated by endogenous glu-cocorticoids in the rat. Gastroenterology 2000;119:1019–28.

21. Kawahito Y, Sano H, Mukai S, et al. Corticotropin releasinghormone in colonic mucosa in patients with ulcerative colitis.Gut 1995;37:544–51.

22. Saunders PR, Hanssen NP, Perdue MH. Cholinergic nervesmediate stress-induced intestinal transport abnormalities inWistar-Kyoto rats. Am J Physiol 1997;273(2 pt 1):G486–90.

23. Santos J, Yang PC, Soderholm JD, et al. Role of mast cells inchronic stress induced colonic epithelial barrier dysfunction inthe rat. Gut 2001;48:630–6.

24. Dhabhar FS, McEwen BS. Stress-induced enhancement ofantigen-specific cell-mediated immunity. J Immunol 1996;156:2608–15.

25. Rogers M, Trentham D, McCune W, et al. Effect of psycho-logical stress on the induction of arthritis in rats. ArthritisRheum 1980;23:1337–42.

26. Dhabhar FS, McEwen BS. Bidirectional effects of stress andglucocorticoid hormones on immune function: Possible expla-nations for paradoxical observations. In: Ader R, Felten DL,Cohen N, eds. Psychoneuroimmunology. 3rd ed. San Diego:Academic Press, 2001.

27. Nigro G, Angelini G, Grosso S, et al. Psychiatric predictors ofnoncompliance in inflammatory bowel disease: Psychiatry andcompliance. J Clin Gastroenterol 2001;32:66–8.

28. Schwarz SP, Blanchard EB. Evaluation of a psychologicaltreatment for inflammatory bowel disease. Behav Res Ther1991;29:167–77.

29. Jantschek G, Zeitz M, Pritsch M, et al. Effect of psychotherapyon the course of Crohn’s disease. Results of the German pro-spective multicenter psychotherapy treatment study on Crohn’sdisease. German Study Group on Psychosocial Intervention inCrohn’s Disease. Scand J Gastroenterol 1998;33:1289–96.

30. Spiro HM. Six physicians with inflammatory bowel disease.J Clin Gastroenterol 1990;12:636–42.

Reprint requests and correspondence: Susan Levenstein, M.D.,Aventino Medical Group, Via della Fonte di Fauno, 22, 00153Rome, Italy.

Received June 17, 2003; accepted June 17, 2003.

Chronic HBV Without e Antigen:Using HBV DNA to GuideManagementAlthough the mainstay for hepatitis B (HBV) diagnosis hasbeen serologic testing with HBV antigens and their corre-sponding antibodies, HBV DNA detection and quantitationare now playing an increasing role in the assessment of viralactivity and response to therapy. In the chronically infectedindividual, the conventional marker of HBV replication isthe hepatitis B e antigen (HBeAg); however, an amino acidsubstitution, most typically in the precore region of the viralgenome (“precore mutant” ), prevents secretion of theHBeAg from the hepatocyte, resulting in negative serologyfor HBeAg in many chronically infected patients. In thesepatients with the precore mutation, HBV DNA is the solemarker of viral activity (1).

The loss of HBeAg and the development of its corre-sponding antibody, anti-HBe, generally indicates a reduc-tion in viral activity and improvement in biochemical andhistologic parameters. This less-active chronic carrier stateof hepatitis B surface antigen (HBsAg)�, HBeAg�, anti-HBe� needs to be differentiated from the precore mutant–infected individual who might have higher risk of continuedviral activity and progressive liver disease. It has also be-come clear that the seroconversion from HBeAg� to anti-HBe� might not mean complete cessation of viral replica-tion. Hsu et al. (2) described the long term follow-up of 283patients who had converted from HBeAg� positivity toanti-HBe positivity and found that over an 8-yr medianfollow-up, 33% had elevation of ALT and HBV DNAconsistent with development of necroinflammation, with 8%eventually developing cirrhosis.

The prevalence of HBeAg-negative chronic hepatitis B–in-fected individuals might be increasing worldwide. Chan et al.reported 17% of HBeAg-negative patients were viremic andhad evidence of chronic hepatitis (3). Minute amounts of pre-core mutant HBV, present even in those who are HBeAg� inserum, are selected after long-term infection and a host im-mune response that has been directed against the HBeAg.Precore mutant–infected individuals might have severe reacti-vation of viral activity and a reduced likelihood of response toviral activity (4). Definitive diagnosis of a precore mutationrequires direct sequencing of the viral genome; however, in theclinical setting, diagnosis of the precore mutant–infected indi-vidual might be suggested by routine testing.

Papatheodoridis and Hadziyannis described the key diag-nostic criteria to suggest HBeAg-negative chronic HBV:infected individuals are persistently HBeAg negative for

2115AJG – October, 2003 Editorials

6–12 months, with elevated ALT levels and positive HBVDNA levels � 105 copies/ml. An HBV DNA level of thismagnitude makes less likely other etiologies of hepaticdysfunction, such as alcohol injury or drug hepatotoxicity.Distinguishing a precore mutant–infected individual froman inactive chronic HBV carrier who has cleared the HBeAgis done based on persistently normal ALT levels on serialtesting and absent or only low levels of HBV DNA in theinactive carrier. Histologically, severe necroinflammatoryactivity and features of chronic hepatitis also support thediagnosis of precore mutant, also known as HBeAg-nega-tive chronic HBV. Strongly positive immunohistochemicalstaining for HBV core antigens in hepatocytes also indicatesactive replication and provides additional evidence for theprecore mutant variant. Patients with HBeAg-negativechronic HBV are typically older than patients with HBeAg-positive disease, reflecting a later stage in the natural historyof long-term infection. Reduced response to antiviral ther-apy is an important consequence of emergence of HBeAg-negative chronic HBV.

Antiviral therapy, initially with interferon alfa, showedhigh end-of-treatment response rates, with improvement inliver chemistries and suppression of HBV DNA in theHBeAg-negative chronic HBV individuals. Unfortunately,viral relapse was almost universal once interferon therapywas stopped (4). More protracted treatment regimens didresult in somewhat increased sustained response rates ap-proaching 22% and even clearance of HBsAg in a smallpercentage (5). Lamivudine therapy is effective in initialsuppression of HBV DNA and normalization of liver chem-istries in HBeAg-negative chronic HBV, but discontinua-tion of lamivudine after 48 wk of therapy resulted in reap-pearance of HBV DNA and biochemical dysfunction.Longer duration lamivudine therapy in this group was lim-ited by viral resistance, although after 3 yr of treatment, onethird of patients were able to maintain normal liver chem-istries and undetectable HBV DNA by polymerase chainreaction (PCR) (6). The absence of a definable endpoint(i.e., loss of HBeAg with seroconversion to anti-HBe pos-itive) in this difficult-to-treat group has made it difficult tomake recommendations regarding optimal duration of ther-apy. The recently introduced adefovir dipivoxil, another well-tolerated oral antiviral, seems to have a much lower rate of viralresistance and might allow the long-term HBV suppression inthe HBeAg-negative chronic HBV patient (7).

As therapy is extended to more HBeAg-negative chronicHBV-infected individuals, the use of HBV DNA testing will beincreasingly incorporated into clinical decision making. A keyissue is quantification of serum HBV DNA to differentiatebetween those with lower levels of viral replication (therefore,presumably less risk of progression of liver disease) and thosewith higher levels of viral activity. Of importance to note, HBVDNA testing was previously performed with less sensitivemolecular hybridization assays, which are now being replacedby PCR technology, which allows for much lower limits ofdetection of HBV DNA in serum, even after years of apparent

recovery from acute HBV (8). Accurate interpretation of HBVDNA quantitative levels requires information as to which par-ticular assay is used for testing.

A recent National Institutes of Health conference on themanagement of HBV selected an HBV DNA level of 105

copies/ml or greater as the threshold level to indicate thepresence of active viral replication. Individuals with serumHBV DNA levels less than this cutoff are deemed “ inactivecarriers,” whereas those with levels greater than 105 cop-ies/ml have chronic infection with ongoing viral activity andmore potential for progressive liver disease. Generally, pa-tients with HBeAg-positive chronic HBV have serum HBVDNA levels exceeding 105 copies/ml. After HBeAg loss andseroconversion to positive anti-HBe, HBV DNA levels fallby a factor of several logs, usually to less than 105 copies/ml. Once again, differentiating between the patient who hassuccessfully seroconverted to positive anti-HBe and thepatient with the HBeAg-negative chronic HBV precore vari-ant might be difficult if less sensitive molecular assays areused that would fail to detect HBV DNA at lower levels.Martinot-Peignoux et al. (9) recently reported on 85HBeAg-negative inactive carriers with persistently normalALT over 6 months (suggesting that these were not precoremutants). Serial HBV DNA testing was performed with aPCR assay capable of detecting as little as 200 copies/ml.They found that 14/85 (16%) had undetectable HBV DNA,and only two patients had levels � 105 copies/ml. Over a6-yr follow-up, serial HBV DNA measurement was done,and only one patient had a rise in viral load, and none hadclinical progression of liver disease. This suggests that theNational Institutes of Health–defined level of �105 cop-ies/ml was useful in identifying inactive disease. Chu andcolleagues reported their experience with 165 Chinese pa-tients with chronic HBV and concurred with this finding(10) but also found that a single HBV DNA measurementwould have misdiagnosed 45% of HBeAg-negative chronicHBV precore variants as inactive carriers, and even testingon three separate occasions would have missed 30% of theHBeAg-negative chronic HBV cases.

In this issue of The American Journal of Gastroenterol-ogy, Manesis et al. (11) assessed baseline HBV DNA levelsin 196 HBeAg-negative patients with the PCR-based RocheAmplicor Monitor assay, which has a lower limit of detec-tion of 400 copies/mL. They found that an HBV DNA levelof �30,000 copies/ml detected 92.9% of those withHBeAg-negative chronic HBV, whereas all inactive carriershad HBV DNA levels � 30,000 copies/ml. However 14 of134 (10.5%) patients with HBeAg-negative chronic hepati-tis B also had serum HBV DNA levels of less than 30,000copies/ml, which emphasizes the potential pitfalls of relyingon a particular HBV DNA level to assign patients to aninactive carrier state or HBeAg chronic HBV. As the au-thors conclude, a single biochemical, serologic, or serumHBV DNA level might not be sufficient for diagnosis.

Perhaps what is more important than defining an absoluteHBV DNA level or assigning a patient into a “category” of

2116 Editorials AJG – Vol. 98, No. 10, 2003

carrier state or HBeAg-negative chronic HBV is recognitionthat in hepatitis B viral infection, an intricate relationshipbetween host and virus results in different patterns of infec-tion. The routine evaluation of a patient with chronic hep-atitis B clearly needs to include the serial measurement ofserum HBV DNA and ALT levels to determine viral repli-cation and potential need for antiviral therapy.

Tram Tran, M.D.Paul Martin, M.D.

Liver Transplant ProgramCedars-Sinai Medical Center

Los Angeles, California

REFERENCES

1. Fattovich G. Natural history and prognosis of hepatitis B.Semin Liv Dis 2003;23:47–58.

2. Hsu YS, Chien RN, Yeh CT, et al. Long-term outcome afterspontaneous HBeAg seroconversion inpatients with chronichepatitis B. Hepatology 2002;35:1522–7.

3. Chan HL, Leung NW, Hussain M. Hepatitis B e antigen-negative chronic hepatitis B in Hong Kong. Hepatology 2000;31:763–8.

4. Papatheodoridis GV, Hadziyannis SJ. Diagnosis and manage-ment of pre-core mutant chronic hepatitis B. J Vir Hepatol2001;8:311–21.

5. Manesis EK, Hadziyannis SJ. Interferon-alpha treatment and

retreatment of hepatitis B e antigen-negative chronic hepatitisB. Gastroenterology 2001;121:91–100.

6. Hadziyannis SJ, Papatheodoridis GV, Vassilopoulos D. Treat-ment of HBeAg-negative chronic hepatitis B. Semin Liv Dis2003;23:81–8.

7. Hadziyannis SJ, Tassopoulos N. Heathcote E, et al. AdefovirDipiroxil for the treatment of hepatitis Be antigen-negativechronic hepatitis B. N Engl J Med 2003;348:800–7.

8. Lok AS, Heathcote EJ, Hoofnagle JH. Management of hepa-titis B 2000: Summary of a workshop. Gastroenterolgy 2001;120:1828–53.

9. Martinot-Peignoux M, Boyer N, Colombat M, et al. Serumhepatitis B virus DNA levels and liver histology in inactiveHBsAg carriers. J Hepatol 2002;36:543–6.

10. Chu CJ, Hussain M, Lok ASF. Quantitative serum HBV DNAlevels during different stages of chronic hepatitis B infection.Hepatology 2002;36:1408–15.

11. Manesis EK, Papatheodoridis GV, Sevastianos V, et al. Sig-nificance of hepatitis B viremia levels determined by a quan-titative polymerase chain reaction assay in patients with hep-atitis B e antigen-negative chronic hepatitis B virus infection.Am J Gastroenterol 2003;98:2261–7.

Reprint requests and correspondence: Paul Martin, M.D., Ce-dars Sinai Medical Center-Los Angeles, Cedars-Sinai MedicalCenter, Liver Transplant Program, 8635 West 3rd Street, Suite590-W, Los Angeles, CA 90048.

Received June 20, 2003; accepted July 8, 2003.

2117AJG – October, 2003 Editorials