Back to Mild to Moderate 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.