Raised transaminases (hepatocellular injury)

Fasting laboratory tests

• AST
• ALT
• GGT
• Alkaline phosphatase
• Bilirubin
• Serum albumin
• PT
• FBC with platelets
• Hepatitis B serology (HBsAg, anti-HBc and anti-HBs antibodies)
• Hepatitis C serology (HCV RNA if positive)
• Serum ferritin
• Transferrin saturation (same sample)
• Fasting plasma glucose
• Lipid profile
• Tissue autoantibodies on triple substrate (antinuclear, anti-smooth muscle, anti-LKM1, antimitochondrial)if needednon-French guidelineImmediately according to the BSG; for the ACG, mainly if there is an associated autoimmune disease (thyroiditis, IBD, rheumatoid arthritis, etc.) or persistent cytolysis ^[1,2].
• IgGif needednon-French guidelineImmediately according to the BSG; for the ACG, mainly if there is an associated autoimmune disease (thyroiditis, IBD, rheumatoid arthritis, etc.) or persistent cytolysis ^[1,2].
• Abdominal ultrasound (not a laboratory test)

Rapid laboratory tests (within the next few days)

• AST
• ALT
• GGT
• Alkaline phosphatase
• Bilirubin
• Serum albumin
• PT
• FBC with platelets
• Anti-HAV IgM
• Hepatitis B serology (HBsAg, anti-HBc and anti-HBs antibodies; anti-HBc IgM added by the laboratory if HBsAg positive)
• Hepatitis C serology (HCV RNA if positive)
• Tissue autoantibodies on triple substrate (antinuclear, anti-smooth muscle, anti-LKM1, antimitochondrial)
• IgG
• Caeruloplasmin
• Anti-HEV IgM
• EBV serologyif needednon-French guidelineAcute hepatitis with no cause found by A, B, C (and E) serologies; mononucleosis-like syndrome; ALT > 1 000 IU/L ^[1,2].
• CMV serologyif needednon-French guidelineAcute hepatitis with no cause found by A, B, C (and E) serologies; mononucleosis-like syndrome; ALT > 1 000 IU/L ^[1,2].
• CK (if intense exercise, trauma or muscle pain)if needednon-French guidelineAST-predominant, intense physical exertion, trauma or muscle signs: exclude a muscular origin (rhabdomyolysis) ^[2].
• Abdominal ultrasound (not a laboratory test)

• No tests in the community: refer the same day to the emergency department or the hepatologist.
• Warning signs: low PT, encephalopathy (confusion, asterixis), unexplained jaundice, possible paracetamol intake.

Laboratory tests

• AST
• ALT
• Alpha-1-antitrypsin
• IgA anti-tissue transglutaminase antibodies (tTG-IgA)
• Total IgA
• TSH
• Creatine kinase (CK)
• Caeruloplasmin (before age 40)if needednon-French guidelineYoung patient: between 3 and 40 years according to the BSG, under 55 years according to the ACG ^[1,2].
• Tissue autoantibodies on triple substrate and IgG (if not already done)if needednon-French guidelineNot done at the first tests: they are part of the BSG basic work-up and of the ACG work-up for persistent abnormalities ^[1,2].
• HEV RNA in blood (immunocompromised patient)if neededImmunocompromised patient (solid organ or stem cell transplant recipient, HIV, haematological malignancy) with persistent cytolysis: in these patients hepatitis E can become chronic ^[7]; HAS places HEV RNA testing in the diagnosis of acute or chronic infection in the immunocompromised ^[7]; the NABM limits it to these situations and to severe acute hepatitis in the immunocompetent ^[3].