Hepatitis A differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Hepatitis A must be differentiated from other diseases that cause fever, nausea, vomiting, jaundice, hepatomegaly, icteric sclera, elevated ALT, AST, and PCR such as other viral hepatitis, alcoholic hepatitis, and autoimmune hepatitis.

Differentiating Hepatitis A from other Diseases

Shown below is a table that summarizes the findings that differentiate hepatitis A from other conditions that cause fever, nausea, vomiting, jaundice, hepatomegaly, and icteric sclera.

Disease	Findings
Viral Hepatitis B	Symptoms are similar to the ones of hepatitis A; however, hepatitis B is a life-threatening condition caused by the hepatitis B virus, that may lead to the development of cirrhosis and liver cancer. Serologic testing will help differentiate these two conditions.
Viral Hepatitis C	Symptoms are similar to the ones of hepatitis A; however, hepatitis C, caused by the hepatitis C virus, can cause acute and/or chronic hepatitis. Serologic testing will help differentiate these two conditions.
Viral Hepatitis D	Symptoms are similar to the ones of hepatitis A; however, hepatitis D is a serious liver disease caused by infection with the hepatitis D virus. Hepatitis D only occurs among people who are infected with the Hepatitis B virus (HBV). It may complicate into cirrhosis and hepatocellular carcinoma. Serologic testing will help differentiate these two conditions.
Viral Hepatitis E	Symptoms are similar to the ones of hepatitis A; however, hepatitis E, caused by the hepatitis E virus, may complicate, in rare cases, into chronic hepatitis and liver failure. Serologic testing will help differentiate these two conditions.
Alcoholic Hepatitis	Symptoms are similar to the ones of hepatitis A; however, alcoholic hepatitis is related to the excessive use of alcohol. Alcoholic hepatitis presents more often with ascites. Alcoholic hepatitis often leads to cirrhosis and liver failure, if alcohol use is not decreased. Serologic testing will help differentiate these two conditions. Also laboratory results show ALT<AST in alcoholic hepatitis (inverse from hepatitis A, in which ALT>AST).
Autoimmune Hepatitis	Autoimmune hepatitis occurs when the body's immune system attacks the hepatocytes. It often affects young females and may present with signs of acute hepatitis or chronic liver disease. Serologic testing will help differentiate these two conditions.

Differential diagnosis of jaundice as one of symptoms of hepatitis A are:

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis Lab Findings Other blood tests Other diagnostic Family history Fever RUQ Pain Pruritis AST ALT ALK BLR Indirect BLR Direct Viral serology Jaundice Hepatocellular Jaundice Liver infiltration: Hemochromatosis, amyloidosis + - -/+ - ↑ ↑ ↑/N ↑/N N - Ferritin ↑ in hemochromatosis Liver biopsy Wilson's disease + - -/+ - ↑ ↑ N ↑/N N - Serum cerulloplasmin ↑ Liver biopsy Viral hepatitis - -/+ - - ↑ ↑ N ↑/N N + Specific viral antibody for each type - Alcoholic hepatitis - -/+ -/+ - ↑↑ ↑ N ↑/N N - - - Drug induced hepatitis - -/+ - - ↑ ↑ N ↑/N N - - - Autoimmune hepatitis -/+ - - -/+ ↑ ↑ N ↑/N N - Anti-LKM antibody Liver biopsy Cirrhosis -/+ -/+ -/+ - ↑ ↑ ↑/N ↑/N ↑/N -/+ Low platate Small liver on ultrasond Nonalcoholic steatohepatitis -/+ - - - ↑ ↑ N ↑/N N - High lipids liver biopsy Ischemic hepatopathy -/+ - -/+ - ↑ ↑ N ↑/N N - Cardiovascular risk factors Clinical setting Cholestatic Jaundice Common bile duct stone -/+ - + + N N ↑ N ↑ - Dilated ducts on sono CT/ERCP Hepatitis A cholestatic type - -/+ + + N N ↑ N ↑ + HAV- AB Abdominal ultrasound EBV / CMV hepatitis - -/+ + + N N ↑ N ↑ + Positive serology - Primary biliary cirrhosis -/+ - -/+ + N/↑ N/↑ ↑ N ↑ - AMA positive Liver biopsy Primary sclerosing cholangitis -/+ - -/+ + N/↑ N/↑ ↑ N ↑ - Pos. autoantibodies Beading on MRCP, Liver biopsy Sickle cell disease + - - +/- N/↑ N/↑ ↑ N ↑ - Genetic testing Pancreatic carcinoma + - -/+ -/+ N/↑ N/↑ ↑ N ↑ - - CT scan for diagnosis AIDS cholangiopathy - - -/+ -/+ N/↑ N/↑ ↑ N ↑ - Pos. HIV Sono or ERCP for diagnosis Parasites induces cholestasis - - -/+ -/+ N/↑ N/↑ ↑ N ↑ - Ab or parasite serology Sono or ERCP for diagnosis Intrahepatic cholestasis of pregnancy -/+ - -/+ + ↑ ↑ ↑ N ↑ - Low PLT, Neg viral serology Diagnosed clinically Isolated Jaundice Crigler-Najjar type 2 + - - - N N N ↑ ↑ - Genetic testing Gilbert + - - - N N N ↑ ↑ - Genetic testing Rotor syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy Dubin-Johnson syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy Hereditory spherocytosis + - -/+ - N N N ↑ N - Genetic testing Osmotic fragility G6PD deficiency + - - - N N N ↑ N - Genetic testing Thalassemia + - - - N N N ↑ N - Genetic testing Paroxismal nocturnal hemoglobinoria - - - - N N N ↑ N - Flocytometery Immune hemolysis - -/+ - - N N N ↑ N - Autoantibodies Hematoma - -/+ - - N N N ↑ N - Anemia Truma or surgery in history