Evaluating Liver Test Abnormalities
Understanding the Pathophysiology of Liver Disease
for Health Care Providers
Acute Viral Hepatitis
Back to Marked Aminotransferase Elevation
Introduction
Among the five hepatotropic viruses, hepatitis A, B and E are the most common causes of acute hepatitis. Hepatitis C is a common cause of chronic hepatitis although it may also present as an acute symptomatic hepatitis. Hepatitis D virus may present as an acute disease, but only in patients with concomitant hepatitis B infection (acute or chronic). Other non-hepatotropic viruses that may cause acute hepatitis include Epstein-Barr virus, cytomegalovirus and herpes simplex viruses.
History
Hepatitis A and E are transmitted by the fecal-oral route. Hepatitis B and C virus are transmitted parenterally. Therefore it is essential to obtain detailed:
- Diet history (particularly raw shellfish)
- History of blood transfusion
- Sexual history
- History of drug use (especially IV drugs)
- Travel history
- History of accompanying viral syndrome (fatigue, fever, anorexia, myalgias, arthralgias, rash, etc)
- History of contact with a jaundiced person
Physical examination
There are no physical signs specific to acute hepatitis of viral etiologies. The following may be present:
- Scleral icterus
- Enlarged tender liver
- Rash (especially with acute HBV and EBV)
- Lymphadenopathy (especially with EBV)
- Splenomegaly (especially with EBV)
- Asterixis
Patients with acute hepatitis who have asterixis or confusion should be urgently referred to a liver specialist or to a transplant center
Laboratory investigation
- Hepatitis A antibody of the IgM type (IgM anti-HAV)
- Hepatitis B core antibody of the IgM type (IgM anti-HBc)
- Hepatitis B surface antigen (HBsAg)
- Hepatitis C antibody (and/or PCR)*
- Serologies and/or PCR for CMV, EBV and HSV (if the tests above are non-revealing)
- Prothrombin time (PT) and INR
Patients with acute hepatitis who have an abnormal PT or INR should be urgently referred to a liver specialist or a transplant center.
*In acute hepatitis C, HCV antibody may be negative. PCR should be obtained if suspicion for HCV infection is high.