EASL clinical practice guidelines: Management of chronic hepatitis B virus infection

2011 Journal of Hepatology 57, 1 (167-185)

Pre-therapeutic assessment of liver disease. [...] Transient elastography, which is a non-invasive method widely used in Europe, offers high diagnostic accuracy for the detection of cirrhosis, although the results may be confounded by severe inflammation associated with high ALT levels and the optimal cut-off of liver stiffness measurements vary among studies.
Indications for treatment. [...]
HBeAg-negative patients with persistently normal ALT levels (ALT determinations at least every 3 months for at least 1 year) and HBV DNA levels above 2000 but below 20,000 IU/ml, without any evidence of liver disease, do not require immediate liver biopsy or therapy (B1). Close follow-up with ALT determinations every 3 months and HBV DNA every 6-12 months for at least 3 years is mandatory (C1). After 3 years, they should be followed for life like all inactive chronic HBV carriers. Evaluation of the severity of fibrosis by a non-invasive method, such as Fibroscan, might be useful in such cases (C2).
Patients with obviously active CHB: HBeAg-positive and HBeAg-negative patients with ALT above 2 times ULN and serum HBV DNA above 20,000 IU/ml may start treatment even without a liver biopsy (B1). In such patients, liver biopsy may provide additional useful information, but it does not usually change the decision for treatment. A non-invasive method for the estimation of the extent of fibrosis and most importantly to confirm or rule out cirrhosis is extremely useful in patients who start treatment without liver biopsy (B1).

Pubmed : 22436845