Treatment Guideline Chart

Hepatitis A route of transmission is through oral-fecal route while in hepatitis E, aside from the oral-fecal route, it is also transmitted through blood transfusion in endemic areas.

Hepatitis A incubation period is 15-50 days and hepatitis E incubation period is 15-60 days.

Hepatitis A & E viruses cause epidemics.


Hepatitis%20a%20-and-%20e Diagnosis


Important Points in the Clinical History of Patients with Suspected Viral Hepatitis

  • Contacts with jaundiced patients
  • IV drug use
  • History of blood transfusion
  • Surgery or hospitalizations
  • Family history of chronic liver disease
  • Occupation
  • Food and water sources

Laboratory Tests

Serological Tests

Hepatitis A

  • Anti-hepatitis A virus (HAV) IgM has high sensitivity and specificity and is a marker of acute infection
    • This test remains positive for ≥6 months
  • Anti-HAV IgG is a marker of previous infection or vaccination
  • Anti-HAV should be tested in patients <50 years

Hepatitis E

  • Positive IgM anti-hepatitis E virus (HEV) in combination with positive HEV RNA indicate acute hepatitis E infection, and positive IgG anti-HEV in combination with positive HEV RNA is diagnostic of chronic hepatitis E infection
  • Detection of HEV antigen by enzyme immunoassays may also be used to diagnose both acute and chronic infections
  • HEV genotype should be determined, if possible, in all HEV-infected persons prior to treatment to determine type and duration of therapy and chances of response; predominant genotypes worldwide are:
    • Genotype 1: Africa and Asia
    • Genotype 2: Mexico, West Africa
    • Genotype 3: Developed countries
    • Genotype 4: China, Taiwan, Japan

Screening Tests to Rule Out Other Viral Hepatitis

  • Hepatitis B: Hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc)
  • Hepatitis C: Anti-hepatitis C virus (anti-HCV) antibody
  • Hepatitis D: Anti-hepatitis D virus (anti-HDV) antibody
  • Please see Hepatitis B and Hepatitis C disease management charts for further information

Nucleic Acid Amplification Test (NAAT)

  • Eg conventional reverse transcription polymerase chain reaction (RT-PCR), real-time RT-PCR, transcription-mediated amplification methods, genotyping for HAV RNA or HEV RNA may be considered
  • HEV RNA is detected from serum and stool of infected patients by NAAT-based assays


  • HEV ORF2 protein immunohistochemistry can be used to establish a histopathologic diagnosis of hepatitis E

Other Recommended Lab Tests in Patients Suspected of Viral Hepatitis

  • Liver function tests (LFTs)
    • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
    • Serum bilirubin, alkaline phosphatase (ALP)
  • Prothrombin time (PT), international normalized ratio (INR), complete blood count (CBC) with platelets, renal function tests
  • Noninvasive tests such as the aminotransferase/platelet ratio index (APRI) or FIB4 may be used to assess the degree of hepatic fibrosis when resources are limited prior to initiating HCV therapy
    • Transient elastography may be an option for patients with contraindications to liver biopsy


Features of Hepatic Decompensation

  • Mental dullness, hepatic encephalopathy, bilateral asterixis, ascites, clinical deterioration
  • Serum bilirubin >2.5x upper limit of normal, PT is 3 seconds longer than control or INR >1.5

Biochemical or Clinical Improvement

  • Repeat liver function test and serum/stool HEV RNA detection will show normalization if patient responded to treatment or infection subsided spontaneously
  • Repeat anti-HAV IgM after 1 week may be used to determine if acute or recent infection has resolved
  • Refer to a specialist if tests are still positive for infection and with disease persistence or progression

Differential Diagnosis

  • Hepatitis B, C, D: Specific serologic testing identifies the different types of hepatitis
  • Epstein-Barr virus, cytomegalovirus: Presents with liver function abnormalities, fever, fatigue, lymphadenopathy
  • Yellow fever virus infection: Signs and symptoms (eg malaise, fever, jaundice) are similar to hepatitis A
  • Herpes simplex virus infection: Usually severe and in immunocompromised patients
  • Adenovirus infection: Gastrointestinal tract involvement overlaps with hepatitis A
  • Human immunodeficiency virus (HIV) infection: Presents as nausea, diarrhea, and anorexia
  • Alcoholic hepatitis: Presents as jaundice, anorexia, fever, tender hepatomegaly, right upper quadrant pain, epigastric pain, hepatic encephalopathy, signs of malnutrition, and increased AST/ALT
  • Drug-induced liver injury (DILI): History of recent use may help in the diagnosis
  • Budd-Chiari syndrome: Patient usually presents with acute or subacute liver disease or acute liver failure; diagnosis is made with the help of ultrasonography
  • Autoimmune hepatitis: Nonspecific symptoms eg malaise, anorexia, nausea, abdominal pain, itching, arthralgia may be confused with hepatitis A and E; serologic testing and histologic findings may help with the diagnosis
  • Wilson disease: Present as acute hepatitis, jaundice, abdominal pain, increased AST/ALT
  • Bacterial infections: Malaria, leptospirosis, syphilis, Q fever


  • More common in adults >50 years old
  • Disease relapse may occur 6 months after resolution of acute illness

Hepatitis A

  • Fulminant hepatitis may occur in patients with underlying hepatic disease or coinfection
    • Liver transplantation may be carefully considered in patients with fulminant hepatic failure and poor prognosis with medical management alone
  • Cholestatic hepatitis
  • Relapsing hepatitis
  • Autoimmune hepatitis

Hepatitis E

  • Neurologic manifestations: Acute meningoencephalitis, acute transverse myelitis, brachial plexus neuritis, Bell palsy, Guillain-Barré syndrome
  • Hematologic manifestations: Severe thrombocytopenia, hemolytic anemia
  • Acute pancreatitis
  • Renal manifestations: Membranoproliferative glomerulonephritis, membranous glomerulonephritis
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