Differentials
Hepatitis A
SIGNS / SYMPTOMS
There may be no differentiating signs and symptoms.
INVESTIGATIONS
Serum laboratory test will be positive for hepatitis A virus-IgM antibody.
Hepatitis C
SIGNS / SYMPTOMS
There may be no differentiating signs and symptoms.
INVESTIGATIONS
Serum hepatitis C virus (HCV) antibody and HCV RNA detected by polymerase chain reaction may be positive for hepatitis C.
Typically, symptomatic acute HCV patients will show very high alanine aminotransferase, aspartate aminotransferase, and bilirubin.
Patients with chronic infection may have normal or elevated liver function tests with positive serum HCV antibody and HCV RNA polymerase chain reaction.
Hepatitis D
SIGNS / SYMPTOMS
There may be no differentiating signs and symptoms.
INVESTIGATIONS
Serum antibody to hepatitis D virus (HDV) may be positive.
Serum HDV RNA on polymerase chain reaction may be positive.
Hepatitis B surface antigen test is positive (HDV cannot propagate without the presence of hepatitis B virus surface antigen).
Hepatitis E
SIGNS / SYMPTOMS
There may be no differentiating signs and symptoms.
INVESTIGATIONS
Antibody to hepatitis E virus (anti-HEV) IgM may be positive.
Anti-HEV IgG may be positive (but may indicate past infection).
HEV RNA serum or stool may be positive.
Cytomegalovirus hepatitis
SIGNS / SYMPTOMS
May have history of immunocompromise including organ transplant.
INVESTIGATIONS
Serum cytomegalovirus (CMV)-IgM antibody and CMV DNA polymerase chain reaction may be positive.
Epstein Barr virus hepatitis
SIGNS / SYMPTOMS
Patients typically can experience fever, fatigue, pharyngitis, malaise, myalgia, and lymphadenopathy (particularly posterior cervical chain).
INVESTIGATIONS
Positive Monospot test and serum heterophile antibody. Serum Epstein Barr virus (EBV)-IgM antibody and EBV DNA polymerase chain reaction may be positive.
Herpes simplex virus hepatitis
SIGNS / SYMPTOMS
Patient may be immunosuppressed or pregnant, but can also be immunocompetent. Patients may present as acute viral hepatitis with or without liver failure.
INVESTIGATIONS
Serum herpes simplex virus (HSV) IgM antibody and HSV DNA polymerase chain reaction may be positive.
Alcohol-related liver disease
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms. History of moderate or heavy alcohol use.
INVESTIGATIONS
Negative serological tests for viral hepatitis. Aspartate aminotransferase level is higher than alanine aminotransferase level, with elevated gamma glutamyl transferase. Liver biopsy may show steatosis, ballooning hepatocytes, Mallory hyaline, lobular neutrophilic infiltration, with or without pericellular fibrosis.
Drug- or toxin-induced hepatitis
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms. There may be a history of exposure to hepatotoxic drugs or toxins.
INVESTIGATIONS
Liver biopsy may show the features of hepatocellular, cholestatic, or mixed pattern of injury, including cholestasis.
Autoimmune hepatitis
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms.
INVESTIGATIONS
There may be increased levels of serum globulin, antinuclear antibody, antismooth muscle antibody, liver/kidney microsomal antibodies, and/or antibodies against soluble liver antigen/liver pancreas antigen. Liver histology may show interface hepatitis with plasma cell infiltrates.
Biliary obstruction
SIGNS / SYMPTOMS
Symptoms associated with biliary obstruction may include right upper quadrant pain, fever/chills, jaundice, pruritus, nausea, and vomiting.
INVESTIGATIONS
Ultrasound, CT scan, or MRI cholangiography may show dilation of biliary tract. In case of malignant obstruction, a mass may be seen in the liver.
Metastatic liver diseases
SIGNS / SYMPTOMS
Patients may be asymptomatic or have symptoms and signs of malignancy of other primary sites, including biliary obstructive features.
INVESTIGATIONS
CT scan or MRI of abdomen may show one or more metastatic masses in the liver.
Acute ischaemic hepatitis
SIGNS / SYMPTOMS
Typically occurs in patients at risk for hypotension or ischaemia, including shock, heart failure, or vascular insufficiency. Patients may have symptoms of ischaemia such as acute heart failure, shock, or sepsis.
INVESTIGATIONS
ECG may show features of myocardial ischaemia or infarction. Chest x-ray and echocardiogram may show features of congestive heart failure. Doppler ultrasound of liver may show portal vein thrombosis or acute occlusion of hepatic artery.
Budd-Chiari syndrome
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms.
INVESTIGATIONS
Doppler ultrasound may show hepatic vein thrombosis or inferior vena caval thrombosis.
Acute fatty liver of pregnancy
SIGNS / SYMPTOMS
Pregnant patient may present with jaundice.
INVESTIGATIONS
Diagnosis of exclusion of other diseases with characteristic symptoms and signs in pregnant patients.
Wilson's disease
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms.
INVESTIGATIONS
Increased urinary copper, decreased serum ceruloplasmin, and Kayser-Fleischer rings on slit lamp eye examination.
Haemochromatosis
SIGNS / SYMPTOMS
There may be no differences in signs and symptoms.
INVESTIGATIONS
High iron saturation (>45% transferrin saturation) and haemochromatosis gene mutations. Liver biopsy shows iron deposition in hepatocytes.
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