Hepatitis, Acute - Acute Hepatitis

  • Diagnosis
  • Algorithms
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • New onset of jaundice, anorexia, or dark urine
  • Known exposure to hepatitis

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 if nonacute presentation
    • Positive HCV antibodies indicate acute HCV or chronic HCV
      • High and low positives should be followed with RNA quantitative testing
  • HEV testing – if patient is from a high-risk area and hepatitis screening tests are negative
  • HDV testing – if acute hepatitis in patient with known chronic hepatitis
  • For further evaluation of hepatitis, refer to specific hepatitis algorithms in ARUP Consult

Differential Diagnosis

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
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.

Hepatic Function Panel 0020416
Method: Quantitative Enzymatic/Quantitative Spectrophotometry

Recommended Use 

Initial screening for hepatobiliary inflammation

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

Recommended Use 

Order to evaluate viral etiology in patients with acute hepatitis

Not recommended for screening asymptomatic patients

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

Hepatitis C Virus by Quantitative PCR 0098268
Method: Quantitative Polymerase Chain Reaction

Recommended Use 

Preferred single test to confirm HCV infection following positive HCV antibody screen

Order only after positive HCV antibody screen

Use to monitor chronic disease

If virus is not detected, result will be reported as <1.2 log IU/mL; if virus is detected but number of copies not accurately quantified, result will be reported as not quantified

Hepatitis Delta Virus by Quantitative PCR 2013881
Method: Quantitative Polymerase Chain Reaction

Recommended Use 

Confirm and quantify the presence of HDV

Hepatitis E Virus (HEV) Antibody, IgG 2010151
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Recommended Use 

Recommended for determining exposure to HEV

Hepatitis E Virus (HEV) Antibody, IgM 2010156
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Recommended Use 

Preferred test for diagnosing acute HEV infection

Hepatitis E Virus by Quantitative PCR 2011654
Method: Quantitative Polymerase Chain Reaction

Recommended Use 

Confirm and quantify the presence of HEV

Limitations 

Negative result (less than 3.3 log IU/mL or less than 1,800 IU/mL) does not rule out the presence of PCR inhibitors in the patient specimen or HEV RNA concentrations below the level of detection of the test

Inhibition may also lead to underestimation of viral quantitation

General References

Aggarwal R, Jameel S. Hepatitis E. Hepatology. 2011; 54(6): 2218-26. PubMed

Clemente MG, Schwarz K. Hepatitis: general principles. Pediatr Rev. 2011; 32(8): 333-40. PubMed

Degertekin B, Lok AS. Update on viral hepatitis: 2007. Curr Opin Gastroenterol. 2008; 24(3): 306-11. PubMed

Denk H. What is expected from the pathologist in the diagnosis of viral hepatitis? Virchows Arch. 2011; 458(4): 377-92. PubMed

Sharapov UM, Hu DJ. Viral hepatitis A, B, and C: grown-up issues. Adolesc Med State Art Rev. 2010; 21(2): 265-86, ix. PubMed

Suriawinata AA, Thung SN. Acute and chronic hepatitis. Semin Diagn Pathol. 2006; 23(3-4): 132-48. PubMed

Medical Reviewers

Hillyard, David R., MD, Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Professor of Clinical Pathology, Adjunct Professor of Biology, University of Utah

Slev, Patricia R., PhD, Medical Director, Serological Hepatitis/Retrovirus, Immunology Core; Co-Medical Director, Microbial Immunology and Immunogenetics; Chief Medical Director, Immunology Division at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Last Update: September 2017