Hepatitis viruses A, B, and C cause 95% of viral hepatitis cases in the U.S. Less common hepatitis viruses include D, E, and G (HGV or GBV-C). Generally, patients meeting the indications for testing should be screened for hepatitis A, B, and C concurrently, unless a specific exposure is known.
Tabs Content Clinical Overview Diagnosis
Indications for Testing
New onset of jaundice, anorexia, or dark urine
Known or suspected exposure to hepatitis virus
Laboratory Testing
Viral hepatitis information 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 if nonacute presentation
Positive HCV antibodies indicate acute HCV or chronic HCV
High and low positives should be followed by RNA quantitative testing
Hepatitis E virus (HEV) testing – if patient is from a high-risk area and hepatitis screening tests are negative
Hepatitis delta virus (HDV) testing – if patient with known chronic hepatitis manifests acute hepatitisFor further evaluation of hepatitis, refer to specific hepatitis algorithms in ARUP Consult
Differential Diagnosis
Virus
Toxin exposure
Nonalcoholic steatohepatitis
Drug-induced hepatitis
Acetaminophen
Antiseizure medications
Isoniazid (Nydrazid)
Oral contraceptives
Rifampin (Rifadin)
Sulfonamides
Autoimmune disease
Bacterial infection
Granulomatous disease
Hereditary disease/disorder
Ischemia
Parasitic infection
Background
Epidemiology
Transmission – variable according to virus
HAV, HEV – fecal-oral
HBV, HCV, HDV, HGV – intravenous (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)
May cause the development of cirrhosis
Patients may remain chronic carriers
Risk Factors
HAV – child daycare settings
HBV and HCV
Sexual transmission via infected partner
HIV IV drug abusers
Infection from blood products (patients with hemophilia )
HDV
IV drug abuse
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 increase in aminotransferases
Mild symptoms – malaise, fever, chills, decreased appetite
Similar symptoms among viral hepatitis types
Jaundice not a predominant symptom in most patients
Complication – acute liver failure
Prevention
Chronic hepatitis is a public health concern in terms of transmission and because it can lead to the development of cirrhosis and hepatocellular carcinoma
Vaccines are available to immunize against HAV and HBV
ARUP Lab Tests
Initial screening for hepatobiliary inflammation
Order to evaluate viral etiology in patients with acute hepatitis
Not recommended for screening asymptomatic patients
Preferred single test to confirm hepatitis C virus (HCV) infection following positive HCV antibody screen
Confirm and quantify presence of HDV
Recommended for determining exposure to HEV
Preferred test for diagnosing acute HEV infection
Confirm and quantify presence of HEV
Negative result (less than 3.3 log IU/mL or less than 1,800 IU/mL) does not rule out presence of PCR inhibitors in patient specimen or HEV RNA concentrations below level of detection of the test
Inhibition may also lead to underestimation of viral quantitation
Diagnose acute hepatitis A virus infection
For panel test that includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody, refer to acute hepatitis panel with reflex to confirmation
Can be ordered as part of acute hepatitis panel which includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody to determine if patient has acute HBV infection
Refer to acute hepatitis panel with reflex to confirmation
Can be ordered as part of acute hepatitis panel which includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody
Refer to acute hepatitis panel with reflex to confirmation
Preferred single screening test for one-time screening of population born between 1945 and 1965 and individuals at risk for HCV
Positive results require confirmation by molecular testing (eg, HCV by quantitative PCR or HCV quantitative PCR with reflex to HCV genotype by sequencing)
Stand-alone antibody testing is recommended
Refer to IgM hepatitis E antibody testing for acute disease or IgG hepatitis E antibody testing for exposure evaluation
Medical Experts Hillyard, David R., MD, Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Professor of Pathology, University of Utah
Slev, Patricia R., PhD, Section Chief, Immunology; Medical Director, Serologic Hepatitis and Retrovirus and Immunology Core Laboratory; Co-Medical Director, Microbial Immunology, at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah
Testing Algorithms Educational Videos Related Topics Last Update: October 2019
