Unifying Concepts

Cost-Effective Laboratory Evaluation of Acute Viral Hepatitis

A cost-effective diagnostic workup of patients with possible acute viral hepatitis is the most reasonable approach. Because 75% of cases of acute viral hepatitis result from infection with either HAV or HBV, the initial laboratory investigation should include serologic tests to exclude HAV or HBV. If the results of these studies are negative, further testing should be done to rule out acute HCV infection, which is less common. Serum HCV RNA is detectable 1 to 2 weeks after the onset of infection, whereas anti-HCV can be detected 8 to 10 weeks following infection with the virus. In clinically stable patients, waiting and checking the presence of antibodies to HCV may be plausible. Checking for HCV RNA by polymerase chain reaction in all patients is not cost-effective, unless there is a known history of blood exposure. Finally, not all acute hepatitis is viral. If the initial evaluation fails to show viral hepatitis, then other causes of hepatitis, such as alcoholic hepatitis, drug toxicity, autoimmune hepatitis, or Wilson’s disease, should be considered.

In patients with findings suggesting acute viral hepatitis, the following studies are done to screen for hepatitis viruses A, B, and C:

  • IgM antibody to HAV (IgM anti-HAV)
  • Hepatitis B surface antigen (HBsAg)
  • IgM antibody to hepatitis B core (IgM anti-HBc)
  • Antibody to HCV (anti-HCV)
  • Hepatitis C RNA (HCV-RNA) polymerase chain reaction (PCR)

If any are positive, further serologic testing may be necessary to differentiate acute from past or chronic infection.

If serologically confirmed HBV infection is severe, anti-HDV is measured.

If the patient has recently traveled to an endemic area or is immunosuppressed, IgM antibody to HEV (IgM anti-HEV) should be measured if the test is available.

This algorithm, however, is not applicable to patients who present with fulminant hepatic failure or who have had chronic viral hepatitis.

Abbreviations: HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HDV, Hepatitis Viral Delta; HEV, hepatitis E virus



  1. Ahmed A, Keeffe EB. Cost-effective evaluation of acute viral hepatitis. West J Med. 2000 Jan;172(1):29-32. [Medline]
  2. Castro R, Crathorne L, Perazzo H, Silva J, Cooper C, Varley-Campbell J, Marinho DS, Haasova M, Veloso VG, Anderson R, Hyde C. Cost-effectiveness of diagnostic and therapeutic interventions for chronic hepatitis C: a systematic review of model-based analyses. BMC Med Res Methodol. 2018 Jun 13;18(1):53. [Medline]
  3. Smith A, Baumgartner K, Cooper J, St Louis J. Liver Disease: Evaluation of Patients With Abnormal Liver Test Results. FP Essent. 2021 Dec;511:11-22. [Medline]


Created Jan 04, 2022.

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