Hepatitis and Laboratory Testing

Hepatitis refers to the condition where the liver becomes inflamed. In most cases, the disease is caused when the liver gets infected by certain viruses. However, it can also be as a result of exposure to chemicals, prescription or over-the-counter drugs, inherited diseases, heavy alcohol use, fatty buildup in the liver, or autoimmune disease.  

The condition can be acute – at first, flaring up before receding within a couple of weeks or a few months-, or chronic, lasting for years. The chronic version of hepatitis can persist for more than 20-years before it starts producing significant symptoms connected to progressive liver damage like liver cancer, cirrhosis, or even death.  

The liver, one of the vital organs in our bodies, is in the upper, right-hand side of our abdomen. The organ is responsible for a barrage of bodily functions, including producing bile juice to help digest fats, processing the body’s nutrients, regulating blood clotting, breaking down toxic substances into harmless ones that our bodies can either eliminate or use, and synthesizing proteins. In severe cases, hepatitis interferes with these processes, allowing potentially toxic substances to build up. 

Types of Hepatitis: 

Viral: Infection with a hepatitis virus causing inflammation; may be chronic or acute, depending on the type of virus. In the United States, hepatitis A, B, & C are the most common causes of infection. 

Drug-induced or Toxic: Our livers process many substances, making them easier for the body to eliminate or use. This process’ byproducts can be toxic to the liver, causing it to get inflamed. In other instances, inflammation occurs when someone takes a drug that isn’t exactly toxic to the organ, but the body identifies it as foreign and attacks it, hence, causing hepatitis. Examples include prescription drugs, over-the-counter pain relievers, industrial chemicals, herbal and vitamin supplements, alcohol.   

Inherited: Gene mutations that are passed on from generation to generation can result in diseases that damage the liver, hence causing hepatitis. Examples include hemochromatosis, a deficiency of alpha-1 antitrypsin, Wilson disease. 

Nonalcoholic fatty liver: When fat deposits in liver cells increase, they increase the liver’s likelihood of injury and inflammation, causing hepatitis. This condition is linked with metabolic syndrome. 

Autoimmune: This is when the immune system incorrectly produces antibodies that attack liver tissues, causing it to become inflamed. The condition is sometimes associated with other types of autoimmune diseases like Sjogren syndrome, pernicious anemia, Hashimoto thyroiditis, type-1 diabetes. 

Signs and Symptoms 

Hepatitis signs and symptoms are all the same, irrespective of the cause; however, they may vary from one person to the other and over time. It is worth noting that most of the people who have chronic hepatitis generally exhibit no symptoms. At the same time, some with acute hepatitis will show no symptoms too, but many have vague or mild symptoms that can easily be mistaken for the flu. Common signs and symptoms of hepatitis include:  

  • Nausea  
  • Fatigue  
  • Joint aches  
  • Abdominal pain 
  • Itching 
  • Yellowing of the skin and eyes (this condition is known as jaundice and is one of the symptoms which strongly suggest that liver damage is the cause of other symptoms) 

Some individuals may experience additional symptoms and signs like dark-colored urine, loss of appetite, or a lighter-colored stool. More severe cases may include complications that involve mental confusion and ascites (accumulation of fluids in the abdomen.) 

Physical examinations tend to reveal that the liver is enlarged and tender. In some people, chronic forms of hepatitis can slowly damage the liver over time, causing liver failure at some point. Chronic forms of hepatitis rarely go away without treatment and typically last for many years. 

Tests  

There are a couple of laboratory tests that can be performed in cases of suspected or known hepatitis. It is worth noting that the available tests fall into either one or more of these categories.  

General Chemistry Tests for Detecting Liver Inflammation and Damage 

  • Screening tests for detecting viral hepatitis. For instance, screening for exposure to types of hepatitis like hepatitis B and hepatitis C can be performed due to increased risks of the disease after donating blood or due to multiple sex partners, use of illegal drugs. 
  • Tests to help identify other underlying causes of the condition 
  • Tests to help guide treatment and monitor the progression of damage to the liver 

 Acute forms of hepatitis are often suspected and tested because of the appearance of symptoms and signs such as loss of appetite, nausea, and fever, often accompanied by pale stools, dark urine, and jaundice (yellow discoloration of the whites of the eyes and the skin.) 

Chronic hepatitis generally has no visible signs and symptoms and is often detected through routine abnormal laboratory tests. These, for example, may include a CMP or comprehensive metabolic panel, which is a group of tests that are generally ordered as part of a liver panel or annual health exam. 

Liver panels and CMPs include a couple of general blood tests that can, in some instances, be used to help assess the liver and detect the condition. They include: 

ALT or Alanine aminotransferase – This is an enzyme that’s primarily found in the liver. When the organ is damaged, the enzyme is released into the bloodstream, often before more obvious signs of damage like jaundice occur. This makes alanine aminotransferase a very useful test for the early detection of damage to the liver. Results are generally compared to those of aspartate aminotransferase or AST tests to help determine liver injury causes.  

AST or Aspartate aminotransferase – AST is another enzyme present in the liver and a couple of other organs, especially the heart and various muscles. The AST test is mostly used to detect liver damage caused by hepatitis and is often more elevated than ALT with exposure to alcoholism, cirrhosis, or drugs that are toxic to the liver. However, AST isn’t specific to the liver and can be increased in conditions that affect other parts of a patient’s body. AST test results are often compared to those of ALT tests. 

ALP or Alkaline phosphatase – ALP is an enzyme that’s related to the bile ducts but is also found in various other tissues in the body. ALP tests are often increased when a patient’s bile ducts are blocked. At the same time, it can be increased if bone disorders are being suspected. 

Bilirubin – This is the waste product produced after old blood cells have been broken down and are processed by the liver in preparation for it to be eliminated. The yellowish compound can start accumulating in the liver when it damaged, causing dark urine and jaundice. 

Albumin – This is the main protein produced by the liver. Since it is a product of the liver, its levels can considerably decrease with a loss of proper liver function. However, this generally only happens when the organ’s function has been seriously affected. It is worth noting that several other conditions could affect the levels of this protein. 

Total protein – albumin and other proteins found in the blood can decrease with debilitating liver disease. 

Depending on the laboratory and the healthcare practitioner, other tests that may be performed as part of a liver panel or individually include:  

PT or Prothrombin time – The PT test might be ordered for persons suspected to have hepatitis or who have hepatitis. The liver mostly makes the proteins that are used to form blood clots, and prolonged prothrombin times tell how severe the damage is! 

GGT or Gamma-glutamyl transpeptidase – This enzyme, found in the organ, is very sensitive to liver function changes. GGT tests help differentiate the causes of elevated ALPs: if gamma-glutamyl transpeptidase is increased, then elevated levels of ALP (Alkaline phosphatase) are due to liver issues rather than bone disease.  

LD or Lactase Dehydrogenase – This enzyme, found in cells all over the body, is released when cells get damaged. 

AFP or Alpha-fetoprotein – This protein is associated with the proliferation or regeneration of liver cells.  

While these general tests may help detect the condition, they don’t determine the root cause. Additional tests may be required to pinpoint the cause and determine the best way to treat it. Examples of these tests include:  

  • An Acute hepatitis panel – can be used to detect hepatitis virus-related infections  
  • Autoimmune antibodies (e.g., ASMA, ANA, anti-LKM-1) – related to autoimmune hepatitis 

For more information about lab tests performed to monitor and diagnose specific types of the condition, click on the links found in the table in the navigation above or on the Overview page.  

Viral Hepatitis  

Infection caused by a virus is one of the most common causes of hepatitis. Five viruses are primarily associated with the condition and are all named in the order they were discovered, i.e., A, B, C, D, and E. Acute viral hepatitis in the United States is generally caused by HAV/hepatitis A virus, HBV/hepatitis B virus, and HCV/hepatitis C virus. It is worth noting that only HCV and HBV infections generally cause chronic hepatitis. 

HAV or hepatitis A virus is highly contagious and is easily spread through food and water that’s been contaminated with the virus. Luckily, since 1995, HAV infections have considerably declined thanks to a vaccine. In 2014, around 1,200 acute HAV cases were reported to the CDC (Centers for Disease Control and Prevention.) The actual numbers might have been slightly higher, but that is because people with mild symptoms or no symptoms at all might not have realized that they were infected. According to the CDC, the number of infections was probably about 2,500, once corrected for asymptomatic infections and underreporting. 

The hepatitis A virus (HAV) only causes acute infections of the disease. In most cases, treatment only involves supportive therapy, and most patients recover fully within six months. During the onset of an HAV infection, our bodies develop antibodies to the virus; so, once the infection has receded, victims will have a developed a lifelong immunity from the infection. 

The hepatitis B virus (HBV) is generally spread by coming into contact with the semen, blood, or other bodily fluids of an infected person. In Europe and North America, HBV is generally spread by sharing syringes, needles, and other drug injecting equipment, from mother to child during pregnancy (though rare in the U.S., it is quite common in other countries around the world); and through sexual contact. 

Not long ago, HBV infections were the most common cause of acute viral hepatitis in America. Luckily, vaccines have led to the infection rate gradually decreasing. According to the Centers for Disease Control and Prevention, there were slightly above 19,000 new cases of hepatitis B virus infections in the U.S. in 2014. While the official reported numbers were much smaller, the number could have been a bit higher, considering that many people do not know that they’re infected and never see a doctor. Hepatitis B virus infections are highest amongst adults, especially men aged between 25 and 44 years.  

The chances of an acute hepatitis B virus infection becoming chronic largely depends on what age the victim becomes infected. The younger someone is infected, the higher the chances the infection will become chronic. Roughly 90 percent of infants who get infected by the disease end up developing chronic infections. On the other hand, less than 5 percent of adults who become infected with the hepatitis B virus develop chronic hepatitis B. 

Acute HBV infection treatments usually only involves supportive therapy. The good thing is that most patients recover fully within six months. During the onset of the infection, our bodies develop antibodies against the virus, which means that after the infection has receded, an infected person will have developed lifelong immunity against the disease. 

People who contract chronic hepatitis B tend to remain free of the symptoms and signs of the condition for decades. However, once diagnosed, drug treatments could help slow the progression or development of liver damage. In the case of liver failure, liver transplantation can be performed. At the same time, there is a list of approved drugs that can be used to treat chronic HBV infections on the Food and Drug Administration’s official website.  

The Hepatitis C virus is generally spread through exposure to contaminated blood, with the most common form of exposure being the sharing of needles and syringes used for injecting drugs of abuse like heroin or cocaine. Another common means of exposure includes the occupational exposure of health workers to used and infected needles; sharing of personal items that might be contaminated with blood like toothbrushes and razors; sexual activities that result in tissue tears; and from a mother to a baby during childbirth. 

There were roughly 30,500 reported cases of acute hepatitis C in America in 2014. But since most cases aren’t reported considering that many people don’t know they are infected due to no visible symptoms, this number could have been higher. Of those infected, about 75 to 85 percent developed chronic hepatitis C. According to data from the CDC, about 3.5 million Americans have chronic hepatitis C. About 60 to 70 percent of people that have untreated chronic hepatitis C end up developing chronic liver disease. If left untreated, about 5 to 20 percent of this number will develop cirrhosis as time goes by, and 1 to 5 percent might die from conditions that result from chronic infections like liver cancer or cirrhosis. 

While there’s currently no vaccine to prevent hepatitis C, research to develop one is still ongoing. Now, the best way to prevent infection is limiting exposure to things that might expose you to HCV, especially the sharing of needles used to inject drugs. Both chronic and acute HCV can be treated using a combination of drugs. For Treatments, see below.  

Hepatitis D and E viruses are quite rare in the United States. It is worth noting that the Hepatitis D virus only causes infections when hepatitis B is present and tends to make the infection worse. The virus is usually spread through exposure to infected needles or blood. The hepatitis E virus is spread in a similar manner as hepatitis A. It is primarily found in Asia, Africa, South and Central America, and the Middle East. However, an increasing number of cases is being reported in American citizens who haven’t traveled to countries in these regions. Hepatitis E can, in rare cases, lead to chronic hepatitis in people whose immune systems aren’t working properly. 

Drug-Induced or Toxic Hepatitis  

The liver’s primary responsibility is to metabolize drugs, alcohol, and other chemicals the body is exposed to, breaking them down to substances that can be used or eliminated by the body. The process rarely creates byproducts that can potentially harm the liver, causing hepatitis. However, symptoms of toxic hepatitis can appear quickly, often within hours or days of being exposed to a harmful substance, while drug-induced hepatitis develops slowly after continued exposure to a chemical or repeated use of a drug or alcohol. 

Toxic Hepatitis 

Good examples of substances or things that cause the liver to create byproducts that are harmful to it or that are directly toxic include pollutants, cleaning solvents, industrial solvents, and a variety of drugs. Acetaminophen, present in most prescription and over-the-counter medications, is a good example of a drug that causes toxic hepatitis. In therapeutic doses, the drug serves as an effective pain reliever. However, in combination with alcohol or in very high doses, it can lead to life-threatening liver failure. 

Drug-Induced Hepatitis  

Some of the most used products capable of instigating drug-induced hepatitis include:  

  • Large doses of vitamin supplements 
  • Herbal supplements, including ephedra, cascara, chaparral, kava, and comfrey 
  • Naproxen sodium, Aspirin, and ibuprofen (especially if combined with alcohol) 

Another common cause of drug-induced hepatitis is excessive consumption of alcohol. Liver inflammation caused by alcohol usage might be chronic but mild, lasting years with no exact symptoms. However, as time goes by, the liver continues to get damaged. The mortality rate in severe alcohol-induced hepatitis (known as alcoholic steatohepatitis) cases is about 50 percent. The good thing is that damage can be reversed if the victim stops consuming alcohol. 

Lots of prescription drugs have the qualities to cause a drug-induced cause of hepatitis. The effects of most drugs on the liver are unforeseen and appear to be related to immune reactions to the drugs. The list of drugs capable of causing damage to the liver is quite long and is still growing. Amongst them are specific types of antifungal and antibiotic medications, anesthetics, seizure medications, chemotherapy drugs, anabolic steroids, and drugs used to lower cholesterol. 

The signs and symptoms of drug-induced and toxic hepatitis tend to vary depending on the root cause. They may develop gradually with continued exposure to specific drugs and toxins or appear suddenly. When present, symptoms, and signs often resemble those of hepatitis. 

Laboratory Tests 

The diagnosis of drug-induced and toxic hepatitis in patients with hepatitis is often reached by obtaining their full medical history with a focus on the use of prescription and over-the-counter medications, vitamin supplements, herbal products, and alcohol use. At the same time, the hazards the patient might have been exposed to at their workplace like industrial solvents are evaluated. Tests that might be performed to examine toxic hepatitis include:  

  • Ethanol level – used if alcohol is thought to be the cause  
  • Liver panel – used to assess liver function and determine liver damage extent  
  • Liver biopsy – used to determine the type of liver damage and its extent 
  • Overdose and emergency drug testing – including tests for acetaminophen, therapeutic drugs, and drugs of abuse to help determine the root cause of hepatitis and the best treatment option  

Inherited Forms of Hepatitis  

There are several inherited diseases that affect the liver, and which become apparent, causing symptoms of chronic or acute hepatitis. Examples include: 

  • Alpha-1-antitrypsin deficiency – This is the number one genetic cause of liver disease in kids. In adults, the deficiency is more likely to affect their lungs, but liver cancer and cirrhosis are also common in people with this disorder. 
  • Hemochromatosis – This is the most common type of inherited hepatitis. It is also associated with the accumulation and absorption of excessive iron by the body. When that happens, the liver is one of the organs in the body that gets damaged. The resulting chronic hepatitis could be because of iron overload. 
  • Wilson disease – This rare inherited disorder leads to a buildup of excess copper in the kidneys, eyes, brain, and liver and may cause both chronic and acute hepatitis. If left untreated, the disease becomes worse and could prove fatal. 

The signs and symptoms of inherited types of hepatitis are quite varied and tend to be specific to the person with the disease. Click on the above links to learn more about them. 

The symptoms and signs of the liver’s involvement in these conditions generally correspond to those of general hepatitis. For more details on those, check out the section on Signs and Symptoms. 

Laboratory Tests  

Inherited hepatitis is suspected if there’s a history of liver disease in the victim’s family. Some of the common tests used to confirm the presence of inherited forms of liver disease include: 

An Alpha-1-antitrypsin level test to determine if there’s a deficiency of alpha-1-antitrypsin. 

Iron tests like ferritin, serum iron, and TIBC or Total Iron Binding Capacity to help identify hemochromatosis  

Copper and ceruloplasmin tests – these can help to diagnose Wilson’s disease. Our bodies normally eliminate excess copper by binding them to an enzyme known as ceruloplasmin before sending them to the bile. With Wilson’s disease, the excretion and binding processed don’t work properly, something that leads to decreased levels of eruloplasmin in the blood and increased levels of free copper in the liver, blood, and urine. 

Liver biopsy – This test involves the microscopic examination of liver tissue samples 

Genetic testing – This test is generally used to detect if there are mutations to specific genes that could lead to inherited forms of hepatitis. Mutation tests in the HFE gene, for instance, can help identify hemochromatosis.  

Nonalcoholic Steatohepatitis (NASH) and Nonalcoholic Fatty Liver Disease (NAFLD) 

One common cause of chronic hepatitis is the buildup of excess fat in the liver. This condition is one that develops gradually over time with the excess intake of calories. In most cases, the first sign is usually abnormal results during routine blood tests. Liver biopsies can be ordered in situations where the liver is enlarged after a viral case of hepatitis and other causes have been ruled out. If tests reveal that the victim’s liver tissues are inflamed, excessively fatty, and are damaged, the condition is referred to as nonalcoholic steatohepatitis. If a liver is fatty but healthy and shows no signs of scarring or inflammation, the condition is referred to as nonalcoholic fatty liver disease. Nonalcoholic steatohepatitis can be severe and may cause cirrhosis. Nonalcoholic fatty liver disease, on the other hand, generally does not have any long-term effects on most effects. However, in a small percentage of the population, it might progressively develop into liver damage. 

Both conditions are commonly seen in individuals with hypertension, metabolic syndrome, high triglyceride levels, a combination of health problems like obesity (especially if they have excessive fat in the belly), insulin resistance, type-2 diabetes, and low HDL cholesterol. Now, there are no specific treatments for these conditions. Nevertheless, those affected are encouraged to lose weight by eating healthy and working out. 

Signs and symptoms aren’t always apparent in individuals with hepatitis that’s been caused by NAFLD. When the signs and symptoms are present, they are generally mild and tend to correspond to those of general hepatitis. Check out the Signs and Symptoms section for more detailed information. 

Tests  

Fatty livers are generally detected when routine tests like a liver panel or a CMP (comprehensive metabolic panel) are done for other reasons. In most cases, abnormal results are the first indication that there’s a problem. Imaging tests like MRI, ultrasound, or CT scan may detect some fat around the liver. In most cases, several lab tests will have to be performed to rule out unrelated causes such as hepatitis C or alcohol. Apart from a liver biopsy, there aren’t any other lab tests that can diagnose NASH or NAFLD. 

Autoimmune Hepatitis  

Autoimmune hepatitis is basically a form of chronic hepatitis that often leads to advanced liver damage. However, in 10 to 20 percent of all cases, it sometimes presents itself as acute hepatitis. When it comes to autoimmune hepatitis, the immune system, for reasons unknown, targets, and attacks the patient’s liver, it is worth noting that this condition mostly affects women. According to the American Liver Foundation (ALF), about 70 percent of those affected by the condition are female aged between 15 and 40. 

There are two known forms of the condition, with the more common one being type I. Type I most commonly affects young females and is sometimes found with other autoimmune disorders like Sjogren syndrome, type-1 diabetes, and ulcerative colitis. Type II isn’t that common and mostly affects girls between 2 and 14 years; it’s more common in European countries than in America. 

Signs and symptoms of the condition resemble those of hepatitis. Check out the Signs and Symptoms section for more detailed information. 

Laboratory Tests  

A couple of tests for various autoantibodies may have to be ordered to help identify autoimmune hepatitis and diagnose other related autoimmune disorders. Common tests include:  

Typically, individuals with type I autoimmune hepatitis tend to have ASMA, ANA, or both, and people with type II have antibodies to liver and kidney microsomes. 

Liver biopsies may have to be performed to identify autoimmune hepatitis and check the presence of cirrhosis. 

Tests: Hepatitis A, B, C testing; Liver Panel; Acute Viral Hepatitis Panel; AST; ALT; ALP; Total Protein; Albumin; Autoantibodies; Bilirubin; SMA; ANA; Anti-LKM-1; Alpha-1 Antitrypsin; Iron Tests; Acetaminophen; Copper; Drug Abuse Testing; Ethanol; Comprehensive Metabolic Panel; Emergency and Overdose Drug Testing.