How is viral hepatitis diagnosed?
Diagnosis of viral hepatitis is based on symptoms and physical findings as well as blood tests for liver enzymes, viral antibodies, and viral genetic materials.
Symptoms and physical findings
Diagnosis of acute viral hepatitis often is easy, but diagnosis of chronic hepatitis can be difficult. When a patient reports symptoms of fatigue, nausea, abdominal pain, darkening of urine, and then develops jaundice, the diagnosis of acute viral hepatitis is likely and can be confirmed by blood tests. On the other hand, patients with chronic hepatitis due to HBV and HCV often have no symptoms or only mild nonspecific symptoms such as chronic fatigue. Typically, these patients do not have jaundice until the liver damage is far advanced. Therefore, these patients can remain undiagnosed for years to decades.
There are three types of blood tests for evaluating patients with hepatitis: liver enzymes, antibodies to the hepatitis viruses, and viral proteins or genetic material (viral DNA or RNA).
Liver enzymes: Among the most sensitive and widely used blood tests for evaluating patients with hepatitis are the liver enzymes, called aminotransferases. They include aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). These enzymes normally are contained within liver cells. If the liver is injured (as in viral hepatitis), the liver cells spill the enzymes into the blood, raising the enzyme levels in the blood and signaling that the liver is damaged.
The normal range of values for AST is from 5 to 40 units per liter of serum (the liquid part of the blood) while the normal range of values for ALT is from 7 to 56 units per liter of serum. (These normal levels may vary slightly depending on the laboratory.) Patients with acute viral hepatitis (for example, due to HAV or HBV) can develop very high AST and ALT levels, sometimes in the thousands of units per liter. These high AST and ALT levels will become normal in several weeks or months as the patients recover completely from their acute hepatitis. In contrast, patients with chronic HBV and HCV infection typically have only mildly elevated AST and ALT levels, but these abnormalities can last years or decades. Since most patients with chronic hepatitis are asymptomatic (no jaundice or nausea), their mildly abnormal liver enzymes are often unexpectedly encountered on routine blood screening tests during yearly physical examinations or insurance physicals.
Elevated blood levels of AST and ALT only means that the liver is inflamed, and elevations can be caused by many agents other than hepatitis viruses, such as medications, alcohol, bacteria, fungi, etc. In order to prove that a hepatitis virus is responsible for the elevations, blood must be tested for antibodies to each of the hepatitis viruses as well as for their genetic material.
Viral antibodies: Antibodies are proteins produced by white blood cells that attack invaders such as bacteria and viruses. Antibodies against the hepatitis A, B, and C viruses usually can be detected in the blood within weeks of infection, and the antibodies remain detectable in the blood for decades thereafter. Blood tests for the antibodies can be helpful in diagnosing both acute and chronic viral hepatitis.
In acute viral hepatitis, antibodies not only help to eradicate the virus, but they also protect the patient from future infections by the same virus, that is, the patient develops immunity. In chronic hepatitis, however, antibodies and the rest of the immune system are unable to eradicate the virus. The viruses continue to multiply and are released from the liver cells into the blood where their presence can be determined by measuring the viral proteins and genetic material. Therefore, in chronic hepatitis, both antibodies to the viruses and viral proteins and genetic material can be detected in the blood.
Examples of tests for viral antibodies are:
- anti-HAV (hepatitis A antibody)
- antibody to hepatitis B core, an antibody directed against the inner core material of the virus (core antigen)
- antibody to hepatitis B surface, an antibody directed against the outer surface envelope of the virus (surface antigen)
- antibody to hepatitis B e, an antibody directed against the genetic material of the virus (e antigen)
- hepatitis C antibody, the antibody against the C virus
Viral proteins and genetic material: Examples of tests for viral proteins and genetic material are:
- hepatitis B surface antigen
- hepatitis B DNA
- hepatitis B e antigen
- hepatitis C RNA
Other tests: Obstruction of the bile ducts, from either gallstones or cancer, occasionally can mimic acute viral hepatitis. Ultrasound testing can be used to exclude the possibility of gallstones or cancer.