Hepatitis, Acute

Diagnosis

Indications for Testing

  • New onset of jaundice, anorexia, or dark urine
  • Known exposure to hepatitis
  • Suspicion of chronic hepatitis (elevated liver enzymes)

Laboratory Testing

  • Viral hepatitis for health professionals (CDC)
  • Screen for hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) infections concurrently unless specific exposure is known
  • Panel testing includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody
    • Positive HAV antibodies indicate acute HAV
    • Positive HBV antibodies and surface antigen indicate acute HBV or chronic hepatitis
      • Repeat surface antigen testing and consider HBV DNA testing
    • Positive HCV antibodies indicate acute HCV or chronic hepatitis
      • High positive should be followed with RNA quantitative testing
      • Low positive should be followed with RIBA and/or RNA quantitative testing
  • HEV testing – if patient is from a high-risk area and hepatitis screening tests are negative
  • For further evaluation of hepatitis, refer to specific hepatitis algorithms in ARUP Consult

Differential Diagnosis

Clinical Background

Hepatitis viruses A (HAV), B (HBV), and C (HCV) cause 95% of viral hepatitis cases in the U.S. Less-common hepatitis viruses include D (HDV), E (HEV), and G (HGV or GBV-C).

Epidemiology

  • Transmission – variable according to virus
    • HAV, HEV – fecal-oral
    • HBV, HCV, HDV, HGV – IV drug abuse, sexual transmission, blood transfusions

Organism

  • Diverse group of viruses that share a common ability to cause inflammation and necrosis of the liver
  • Virus may persist in a chronic state (HBV, HCV, HDV)
    • Patients may remain chronic carriers
    • May cause the development of cirrhosis

Risk Factors

  • HAV – children in daycare settings
  • HBV and HCV
    • Sexual transmission from infected partner
    • HIV-positive patients
    • IV drug abusers
    • Hemophiliacs – from blood products
  • HDV
    • IV drug abusers
    • Travel to endemic area (Amazon basin, Mediterranean basin, Middle East, South Pacific, Asia, Sub-Saharan Africa)
  • HEV
    • Travel to endemic area (Central Asia, Middle East, parts of South America, Africa)

Clinical Presentation

  • May be difficult to diagnose clinically
  • Frequently asymptomatic – may have only mild rise in aminotransferases
  • Mild symptoms – malaise, fever, chills, depressed appetite
  • Similar symptoms among viral hepatitis types
  • Jaundice is not a predominant symptom in most patients
  • Complications – acute liver failure

Prevention

  • Chronic hepatitis is a public health concern for transmission as well as for the development of cirrhosis and hepatocellular carcinoma
  • Vaccines are available to immunize against HAV and HBV

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Hepatic Function Panel 0020416
Method: Quantitative Enzymatic/Quantitative Spectrophotometry

Initial screening for hepatobiliary complications

Panel includes albumin; ALP; AST; ALT; bilirubin, direct; protein, total; and bilirubin, total

    
Hepatitis Panel, Acute with Reflex to HBsAg Confirmation 0020457
Method: Qualitative Chemiluminescent Immunoassay

Order when patient has had clinical acute hepatitis of unknown origin for less than 6 months

Panel includes HAV IgM, HBV core antibody IgM, HBV surface antigen, HCV antibody

Positive HAV IgM shows current or recent infection with 98% sensitivity and specificity

    
Hepatitis C Virus RNA Quantitative, Real-Time PCR 0098268
Method: Quantitative Real-Time Polymerase Chain Reaction

Follow-up test for high-positive anti-HCV screen

The limit of quantification for the HCV Quantitative RNA assay is 1.6 log IU/mL (43 IU/mL)

If the assay DID NOT DETECT the virus, the test result will be reported as “<1.6 log IU/mL (<43 IU/mL)”; if the assay DETECTED the presence of the virus but was not able to accurately quantify the number of copies, the test result will be reported as “Not Quantified”

  
Hepatitis E Antibody, IgG 0098655
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Confirm HEV when other testing is negative

    
Hepatitis E Antibody, IgM 0098656
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Confirm HEV when other testing is negative

    
Additional Tests Available
 
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Hepatitis A Virus Antibody, IgM 0020093
Method: Qualitative Chemiluminescent Immunoassay
Hepatitis B Virus Core Antibody, IgM 0020092
Method: Qualitative Chemiluminescent Immunoassay
Hepatitis B Virus Surface Antigen with Reflex to Confirmation 0020089
Method: Qualitative Chemiluminescent Immunoassay 
Hepatitis C Virus Antibody by CIA 2002483
Method: Qualitative Chemiluminescent Immunoassay

Diagnostic Algorithm