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Autoimmune hepatitis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Autoimmune hepatitis must be differentiated from other diseases that cause jaundice, nausea and vomiting, abdominal pain, arthragia, and hepatomegaly such as hepatitis A, B, C, E, drug-induced hepatitis, CMV hepatitis, EBV hepatitis, alcoholic hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis.

Differentiating autoimmune hepatitis from other diseases

Autoimmune hepatitis must be differentiated from other diseases that cause jaundice, nausea and vomiting, abdominal pain, arthragia, and hepatomegaly such as Hepatitis A,B,C, E, drug induced hepatitis, CMV hepatitis, EBV hepatitis, alcoholic hepatitis, Primary biliary cirrhosis and Primary sclerosing cholangitis.[1][2][3][4][5][6][7][8][9]

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
Family history Fever RUQ Pain Pruritis AST ALT ALP BLR Indirect BLR Direct Viral serology
Jaundice Hepatocellular Jaundice Infiltrative liver disorders: Hemochromatosis, amyloidosis + – -/+ – ↑ ↑ ↑/N ↑/N N – Ferritin ↑ (hemochromatosis) Liver biopsy
Wilson’s disease + – -/+ – ↑ ↑ N ↑/N N – ↑ Serum ceruloplasmin Liver biopsy
Viral hepatitis – -/+ – – ↑ ↑ N ↑/N N + Specific viral antibody for each type –
Alcoholic hepatitis – -/+ -/+ – ↑↑ ↑ N ↑/N N – – –
Drug induced hepatitis – -/+ – – ↑ ↑ N ↑/N N – – –
Autoimmune hepatitis -/+ – – -/+ ↑ ↑ N ↑/N N – Anti-LKM antibody Liver biopsy
Cirrhosis -/+ -/+ -/+ – ↑ ↑ ↑/N ↑/N ↑/N -/+ Low platate Small liver on ultrasond
Nonalcoholic steatohepatitis -/+ – – – ↑ ↑ N ↑/N N – Dyslipidemia liver biopsy
Ischemic hepatopathy -/+ – -/+ – ↑ ↑ N ↑/N N – Cardiovascular risk factors –
Cholestatic Jaundice Common bile duct stone -/+ – + + N N ↑ N ↑ – Dilated ducts on ultrasound CT/ERCP
Hepatitis A (cholestatic type) – -/+ + + N/↑ N/↑ ↑ N ↑ + HAV- Ab Abdominal ultrasound
EBV / CMV hepatitis – -/+ + + N N ↑ N ↑ + Positive serology –
Primary biliary cirrhosis -/+ – -/+ + N/↑ N/↑ ↑ N ↑ – AMA positive Liver biopsy
Primary sclerosing cholangitis -/+ – -/+ + N/↑ N/↑ ↑ N ↑ – ↑Autoantibodies (P-ANCA), hypergammaglobulinemia MRCP,

Liver biopsy

Sickle cell disease + – – +/- N/↑ N/↑ ↑ N ↑ – Genetic testing
Pancreatic carcinoma + – -/+ -/+ N/↑ N/↑ ↑ N ↑ – – CT scan for diagnosis
AIDS cholangiopathy – – -/+ -/+ N/↑ N/↑ ↑ N ↑ – HIV Ab Ultrasound or ERCP
Parasites induces cholestasis – – -/+ -/+ N/↑ N/↑ ↑ N ↑ – Serology Ultrasound or ERCP
Intrahepatic cholestasis of pregnancy -/+ – -/+ + ↑ ↑ ↑ N ↑ – Thrombocytopenia Diagnosed clinically
Isolated Jaundice Crigler-Najjar type 2 + – – – N N N ↑ ↑ – Genetic testing
Gilbert + – – – N N N ↑ ↑ – Genetic testing
Rotor syndrome + – – – N N N N ↑ – Genetic testing Liver biopsy
Dubin-Johnson syndrome + – – – N N N N ↑ – Genetic testing Liver biopsy
Hereditary spherocytosis + – -/+ – N N N ↑ N – Genetic testing Osmotic fragility
G6PD deficiency + – – – N N N ↑ N – Genetic testing
Thalassemia + – – – N N N ↑ N – Genetic testing
Paroxysmal nocturnal hemoglobinuria – – – – N N N ↑ N – Flocytometery
Immune hemolysis – -/+ – – N N N ↑ N – Autoantibodies
Hematoma – -/+ – – N N N ↑ N – Anemia Truma or surgery in history

References

  1. ↑ Selmi C, Bowlus CL, Gershwin ME, Coppel RL (2011). “Primary biliary cirrhosis”. Lancet. 377 (9777): 1600–9. doi:10.1016/S0140-6736(10)61965-4. PMID 21529926.
  2. ↑ Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ (2009). “Primary biliary cirrhosis”. Hepatology. 50 (1): 291–308. doi:10.1002/hep.22906. PMID 19554543.
  3. ↑ Koff RS (1998). “Hepatitis A”. Lancet. 351 (9116): 1643–9. doi:10.1016/S0140-6736(98)01304-X. PMID 9620732.
  4. ↑ Ciocca M (2000). “Clinical course and consequences of hepatitis A infection”. Vaccine. 18 Suppl 1: S71–4. PMID 10683554.
  5. ↑ Fargo MV, Grogan SP, Saguil A (2017). “Evaluation of Jaundice in Adults”. Am Fam Physician. 95 (3): 164–168. PMID 28145671.
  6. ↑ Leevy CB, Koneru B, Klein KM (1997). “Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease”. Gastroenterology. 113 (3): 966–72. PMID 9287990.
  7. ↑ Hov JR, Boberg KM, Karlsen TH (2008). “Autoantibodies in primary sclerosing cholangitis”. World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433. PMID 18609700.
  8. ↑ Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). “Gall stones in sickle cell disease in the United Kingdom”. Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079. PMID 3115390.
  9. ↑ Malakouti M, Kataria A, Ali SK, Schenker S (2017). “Elevated Liver Enzymes in Asymptomatic Patients – What Should I Do?”. J Clin Transl Hepatol. 5 (4): 394–403. doi:10.14218/JCTH.2017.00027. PMC 5719197. PMID 29226106.

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