eMedicine Specialties > Gastroenterology > Liver

Hepatitis D: Differential Diagnoses & Workup

Author: Sean R Lacey, MD, Consulting Staff, Department of Medicine, Division of Gastroenterology, Gastroenterology Associates, Ltd, Lehigh Valley Hospital
Contributor Information and Disclosures

Updated: Oct 31, 2006

Differential Diagnoses

Alcoholic Hepatitis
Hepatitis B
Autoimmune Hepatitis
Hepatitis C
Bile Duct Strictures
Hepatitis E
Biliary Obstruction
Hyperbilirubinemia, Conjugated
Budd-Chiari Syndrome
Isoniazid Hepatotoxicity
Cholangitis
Liver Abscess
Cholecystitis
Hepatitis A

Other Problems to Be Considered

Acetaminophen poisoning
Drug-induced hepatitis
Fatty liver of pregnancy
HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome in pregnant patients
Ischemic liver injury
Mushroom toxicity

Workup

Laboratory Studies

  • The following serum test results are present in patients with co-infection with HDV and HBV:
    • Results are positive for HDV antigen in 20%.
    • Results are positive for HDV RNA in 90%. Reverse transcriptase polymerase chain reaction is currently the most sensitive assay for the detection of HDV viremia.
    • Results for anti-HDV immunoglobulin M (IgM) are positive initially and then are positive for anti-HDV immunoglobulin G. The finding of antigen A antibody to HDV is almost exclusively associated with chronic HDV infections.
    • Results for anti-HB core IgM are positive, except with superinfection, in which anti-HB core IgM is absent.
    • A hepatic panel may show alanine aminotransferase and aspartate aminotransferase levels greater than 500 IU/L.
    • For synthetic liver function markers, an international normalized ratio greater than 1.5 or a prothrombin time greater than 17 seconds may be the first evidence of fulminant liver failure.
  • HBsAg is required for HDV replication but may be suppressed to undetectable levels with active HDV replication.

Imaging Studies

  • Right upper quadrant ultrasound helps evaluate for biliary obstruction and hepatocellular carcinoma.
  • Perform cholescintigraphy (hydroxy iminodiacetic acid) to exclude acute cholecystitis, if clinically indicated.
  • Perform CT scanning or MRI if hepatocellular carcinoma is suggested. An alpha-fetoprotein level greater than 250 ng/mL is highly suggestive of hepatocellular carcinoma.

Procedures

  • Results from liver biopsy in patients with acute disease are consistent with acute hepatitis, and, generally, a biopsy is not indicated. In patients with chronic liver disease, liver biopsy is indicated to evaluate for the presence of fibrosis and cirrhosis.
  • HDV antigen immunohistochemical analysis of liver tissue is the criterion standard for establishing a diagnosis of persistent HDV infection.

Histologic Findings

Features are very similar to those observed in patients with HBV infection. Acidophilic bodies and degeneration of hepatocytes with acidophilic cytoplasm are present. The few inflammatory cells (lymphocytes) likely represent the direct cytotoxicity of HDV. Results of immunohistochemical staining for HDV antigen are positive. With superinfection, staining reveals that HBsAg is often suppressed.

More on Hepatitis D

Overview: Hepatitis D
Differential Diagnoses & Workup: Hepatitis D
Treatment & Medication: Hepatitis D
Follow-up: Hepatitis D
References
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References

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Further Reading

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Keywords

HDV, HDV infection, viral hepatitis, delta hepatitis, delta virus, hepatitis delta, hepatitis B virus, HBV, hepatitis B surface antigen, HBsAg, liver failure, liver infection, acute fulminant liver failure, chronic liver infection, end-stage liver disease, end-stage liver disease, ESLD, cirrhosis, hepatocellular carcinoma, HCC, liver transplantation, hepatic transplantation

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Contributor Information and Disclosures

Author

Sean R Lacey, MD, Consulting Staff, Department of Medicine, Division of Gastroenterology, Gastroenterology Associates, Ltd, Lehigh Valley Hospital
Sean R Lacey, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association
Disclosure: astra zenaca Honoraria Speaking and teaching

Medical Editor

David Eric Bernstein, MD, Chief, Section of Hepatology, North Shore University Hospital, Director, Associate Professor, Department of Internal Medicine, Division of Hepatology, New York University School of Medicine
David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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