Hepatitis C differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Yazan Daaboul, Serge Korjian

Overview

Hepatitis C must be differentiated from other diseases that cause hepatic injury and abnormal liver function tests such as other viral hepatitides (Hepatitis A, Hepatitis B, and Hepatitis E) and non-viral etiologies such as alcoholic liver disease, non-alcoholic steatohepatitis, drug-induced liver injury, autoimmune hepatitis, hepatocellular carcinoma, liver abscess, pancreatitis, and bowel obstruction.

Differential Diagnosis

The differential diagnosis of hepatitis C includes other etiologies of viral hepatitis and non-viral etiologies:^[1]

Viral Hepatitis Differential Diagnosis

Non-Viral Hepatitis Differential Diagnosis

Autoimmune hepatitis
Alcoholic liver disease
Non-alcoholic steatohepatitis (NASH)
Drug-induced liver injury (DILI)
Liver abscess
Hepatocellular carcinoma
Cholelithiasis
Cholecystitis
Cholangitis
Chronic biliary disease
Trauma
Abdominal aneurysm
Gastritis
Gastroenteritis
Peptic ulcer disease
Bowel obstruction
Pancreatitis
Pancreatic cancer
Malignant lymphoma
Hereditary metabolic disorders (Wilson disease, alpha-1 antitrypsin deficiency)

Differential diagnosis of jaundice are: ^[2]^[3]^[4]^[5]^[6]

Classification of jaundice based on etiology		Disease	History and clinical manifestations				Diagnosis
			History and clinical manifestations				Lab Findings						Other blood tests	Other diagnostic
			Family history	Fever	RUQ Pain	Pruritis	AST	ALT	ALK	BLR Indirect	BLR Direct	Viral serology	Other blood tests	Other diagnostic
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

References

↑ Giannini EG, Testa R, Savarino V (2005). "Liver enzyme alteration: a guide for clinicians". CMAJ. 172 (3): 367–79. doi:10.1503/cmaj.1040752. PMC 545762. PMID 15684121.
↑ Fargo MV, Grogan SP, Saguil A (2017). "Evaluation of Jaundice in Adults". Am Fam Physician. 95 (3): 164–168. PMID 28145671.
↑ Leevy CB, Koneru B, Klein KM (1997). "Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease". Gastroenterology. 113 (3): 966–72. PMID 9287990.
↑ Hov JR, Boberg KM, Karlsen TH (2008). "Autoantibodies in primary sclerosing cholangitis". World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433. PMID 18609700.
↑ Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). "Gall stones in sickle cell disease in the United Kingdom". Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079. PMID 3115390.
↑ Malakouti M, Kataria A, Ali SK, Schenker S (2017). "Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do?". J Clin Transl Hepatol. 5 (4): 394–403. doi:10.14218/JCTH.2017.00027. PMC 5719197. PMID 29226106.

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[pmid15684121-1] Giannini EG, Testa R, Savarino V (2005). "Liver enzyme alteration: a guide for clinicians". CMAJ. 172 (3): 367–79. doi:10.1503/cmaj.1040752. PMC 545762. PMID 15684121.

[pmid28145671-2] Fargo MV, Grogan SP, Saguil A (2017). "Evaluation of Jaundice in Adults". Am Fam Physician. 95 (3): 164–168. PMID 28145671.

[pmid9287990-3] Leevy CB, Koneru B, Klein KM (1997). "Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease". Gastroenterology. 113 (3): 966–72. PMID 9287990.

[pmid18609700-4] Hov JR, Boberg KM, Karlsen TH (2008). "Autoantibodies in primary sclerosing cholangitis". World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433. PMID 18609700.

[pmid3115390-5] Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). "Gall stones in sickle cell disease in the United Kingdom". Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079. PMID 3115390.

[pmid29226106-6] Malakouti M, Kataria A, Ali SK, Schenker S (2017). "Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do?". J Clin Transl Hepatol. 5 (4): 394–403. doi:10.14218/JCTH.2017.00027. PMC 5719197. PMID 29226106.

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