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Blood testing includes [[Liver function tests|liver enzymes]], [[serology]] (i.e. for autoantibodies), [[nucleic acid test]]ing (i.e. for hepatitis virus DNA/RNA), [[Blood chemistry study|blood chemistry]], and [[complete blood count]].<ref name="Friedman 55e" /> Characteristic patterns of liver enzyme abnormalities can point to certain causes or stages of hepatitis.<ref>{{cite journal|last=Green|first=RM|date=October 2002|title=AGA technical review on the evaluation of liver chemistry tests|journal=Gastroenterology|volume=123|issue=4|pages=1367–84|doi=10.1053/gast.2002.36061|pmid=12360498|author2=Flamm, S}}</ref><ref>{{cite journal|last=Pratt|first=DS|date=Apr 27, 2000|title=Evaluation of abnormal liver-enzyme results in asymptomatic patients|journal=The New England Journal of Medicine|volume=342|issue=17|pages=1266–71|doi=10.1056/NEJM200004273421707|pmid=10781624|author2=Kaplan, MM}}</ref> Generally, [[Aspartate transaminase|AST]] and [[Alanine transaminase|ALT]] are elevated in most cases of hepatitis regardless of whether the person shows any symptoms.<ref name="Friedman 55e" /> The degree of elevation (i.e. levels in the hundreds vs. in the thousands), the predominance for AST vs. ALT elevation, and the ratio between AST and ALT are informative of the diagnosis.<ref name="Friedman 55e" />
[[Medical ultrasound|Ultrasound]], [[CT scan|CT]], and [[Magnetic resonance imaging|MRI]] can all identify steatosis (fatty changes) of the liver tissue and nodularity of the liver surface suggestive of cirrhosis.<ref>{{Cite journal|last1=Ito|first1=Katsuyoshi|last2=Mitchell|first2=Donald G.|title=Imaging Diagnosis of Cirrhosis and Chronic Hepatitis|journal=Intervirology|volume=47|issue=3–5|pages=134–143|doi=10.1159/000078465|pmid=15383722|year=2004|s2cid=36112368}}</ref><ref>{{Cite journal|last1=Allan|first1=Richard|last2=Thoirs|first2=Kerry|last3=Phillips|first3=Maureen|date=2010-07-28|title=Accuracy of ultrasound to identify chronic liver disease|journal=World Journal of Gastroenterology|volume=16|issue=28|pages=3510–3520|doi=10.3748/wjg.v16.i28.3510|issn=1007-9327|pmc=2909550|pmid=20653059}}</ref> CT and especially MRI are able to provide a higher level of detail, allowing visualization and characterize such structures as vessels and tumors within the liver.<ref>{{Cite journal|last1=Sahani|first1=Dushyant V.|last2=Kalva|first2=Sanjeeva P.|date=2004-07-01|title=Imaging the Liver|journal=The Oncologist|language=en|volume=9|issue=4|pages=385–397|doi=10.1634/theoncologist.9-4-385|issn=1083-7159|pmid=15266092|doi-access=free}}</ref> Unlike steatosis and cirrhosis, no imaging test is able to detect liver inflammation (i.e. hepatitis) or fibrosis.<ref name="Friedman 55e" /> Liver biopsy is the only definitive diagnostic test that is able to assess inflammation and fibrosis of the liver.<ref name="Friedman 55e" />
=== Viral hepatitis ===
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Initial accounts of a syndrome that we now think is likely to be hepatitis begin to occur around 3000 B.C. Clay tablets that served as medical handbooks for the ancient Sumerians described the first observations of jaundice. The Sumerians believed that the liver was the home of the soul, and attributed the findings of jaundice to the attack of the liver by a devil named [[Akhkhazu|Ahhazu]].<ref>{{cite journal |last1=Trepo |first1=Christian |date=February 2014 |title=A brief history of hepatitis milestones |journal=Liver International |volume=34 |issue=Supplement s1 |pages=29–37 |doi=10.1111/liv.12409|pmid=24373076 |s2cid=41215392 |doi-access=free }}</ref>
Around 400 B.C., [[Hippocrates]] recorded the first documentation of an epidemic jaundice, in particular noting the uniquely fulminant course of a cohort of patients who all died within two weeks. He wrote, "The bile contained in the liver is full of phlegm and blood, and erupts...After such an eruption, the patient soon raves, becomes angry, talks nonsense and barks like a dog."<ref>{{cite journal |date=July 2012 |title=Viral hepatitis—the silent killer. |journal=Annals of the Academy of Medicine, Singapore |volume=41 |issue=7 |pages=279–80 |pmid=22892603 |last1=Oon |first1=GC|doi=10.47102/annals-acadmedsg.V41N7p279 |s2cid=2757948 |doi-access=free }}</ref>
Given the poor sanitary conditions of war, infectious jaundice played a large role as a major cause of mortality among troops in the Napoleonic Wars, the American Revolutionary War, and both World Wars.<ref>{{cite book |title=Classic papers in viral hepatitis |editor1-last=Lee |editor1-first=Christine A. |editor2-last=Thomas |editor2-first=Howard C. |date=1988 |publisher=Science Press |isbn=978-1-870026-10-9 |location=London, England |others=Foreword by Dame Sheila Sherlock}}</ref> During World War II, estimates of soldiers affected by hepatitis were upwards of 10 million.
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Overall, hepatitis accounts for a significant portion of healthcare expenditures in both developing and developed nations, and is expected to rise in several developing countries.<ref name="Udompap, Kim & Kim">{{Cite journal|last1=Udompap|first1=Prowpanga|last2=Kim|first2=Donghee|last3=Kim|first3=W. Ray|date=2015-11-01|title=Current and Future Burden of Chronic Nonmalignant Liver Disease|journal=Clinical Gastroenterology and Hepatology|volume=13|issue=12|pages=2031–2041|doi=10.1016/j.cgh.2015.08.015|issn=1542-7714|pmc=4618163|pmid=26291665}}</ref><ref name="Reducing the neglected burden">{{Cite journal|last1=Lemoine|first1=Maud|last2=Eholié|first2=Serge|last3=Lacombe|first3=Karine|title=Reducing the neglected burden of viral hepatitis in Africa: Strategies for a global approach|journal=Journal of Hepatology|volume=62|issue=2|pages=469–476|doi=10.1016/j.jhep.2014.10.008|pmid=25457207|year=2015|doi-access=free}}</ref> While hepatitis A infections are self-limited events, they are associated with significant costs in the United States.<ref name="Current Childhood Vaccination Strategies">{{Cite journal|last1=Koslap-Petraco|first1=Mary Beth|last2=Shub|first2=Mitchell|last3=Judelsohn|first3=Richard|title=Hepatitis A: Disease Burden and Current Childhood Vaccination Strategies in the United States|journal=Journal of Pediatric Health Care|volume=22|issue=1|pages=3–11|doi=10.1016/j.pedhc.2006.12.011|pmid=18174084|year=2008}}</ref> It has been estimated that [[Direct cost|direct and indirect costs]] are approximately $1817 and $2459 respectively per case, and that an average of 27 work days is lost per infected adult.<ref name="Current Childhood Vaccination Strategies"/> A 1997 report demonstrated that a single hospitalization related to hepatitis A cost an average of $6,900 and resulted in around $500 million in total annual healthcare costs.<ref>{{Cite web|url=https://www.who.int/csr/disease/hepatitis/HepatitisA_whocdscsredc2000_7.pdf?ua=1|title=Hepatitis A|last1=Previsani|first1=Nicoletta|last2=Lavanchy|first2=Daniel|date=2000|website=World Health Organization Global Alert and Response|publisher=World Health Organization|access-date=March 5, 2016}}</ref> Cost effectiveness studies have found widespread vaccination of adults to not be feasible, but have stated that a combination hepatitis A and B vaccination of children and at risk groups (people from endemic areas, healthcare workers) may be.<ref>{{Cite journal|last1=Anonychuk|first1=Andrea M.|last2=Tricco|first2=Andrea C.|last3=Bauch|first3=Chris T.|last4=Pham|first4=Ba'|last5=Gilca|first5=Vladimir|last6=Duval|first6=Bernard|last7=John-Baptiste|first7=Ava|last8=Woo|first8=Gloria|last9=Krahn|first9=Murray|date=2008-01-01|title=Cost-effectiveness analyses of hepatitis A vaccine: a systematic review to explore the effect of methodological quality on the economic attractiveness of vaccination strategies|journal=PharmacoEconomics|volume=26|issue=1|pages=17–32|issn=1170-7690|pmid=18088156|doi=10.2165/00019053-200826010-00003|s2cid=46965673}}</ref>
Hepatitis B accounts for a much larger percentage of health care spending in endemic regions like Asia.<ref>{{Cite journal|last1=Chan|first1=Henry Lik-Yuen|last2=Jia|first2=Jidong|date=2011-01-01|title=Chronic hepatitis B in Asia—new insights from the past decade|journal=Journal of Gastroenterology and Hepatology|language=en|volume=26|pages=131–137|doi=10.1111/j.1440-1746.2010.06544.x|pmid=21199524|s2cid=23548529|issn=1440-1746|doi-access=free}}</ref><ref name="Economics of treating in Asia">{{Cite journal|last1=Dan|first1=Yock Young|last2=Aung|first2=Myat Oo|last3=Lim|first3=Seng Gee|date=2008-09-01|title=The economics of treating chronic hepatitis B in Asia|journal=Hepatology International|volume=2|issue=3|pages=284–295|doi=10.1007/s12072-008-9049-2|issn=1936-0533|pmc=2716880|pmid=19669256}}</ref> In 1997 it accounted for 3.2% of South Korea's total health care expenditures and resulted in $696 million in direct costs.<ref name="Economics of treating in Asia" /> A large majority of that sum was spent on treating disease symptoms and complications.<ref>{{Cite journal|last=Lavanchy|first=D.|date=2004-03-01|title=Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures|journal=Journal of Viral Hepatitis|volume=11|issue=2|pages=97–107|issn=1352-0504|pmid=14996343|doi=10.1046/j.1365-2893.2003.00487.x|s2cid=163757}}</ref> Chronic hepatitis B infections are not as endemic in the United States, but accounted for $357 million in hospitalization costs in the year 1990.<ref name="Udompap, Kim & Kim" /> That number grew to $1.5 billion in 2003, but remained stable as of 2006, which may be attributable to the introduction of effective drug therapies and vaccination campaigns.<ref name="Udompap, Kim & Kim" /><ref name="Reducing the neglected burden" />
People infected with chronic hepatitis C tend to be frequent users of the health care system globally.<ref name="Younossi, Kanwal, Saab, et al">{{Cite journal|last1=Younossi|first1=Z. M.|last2=Kanwal|first2=F.|last3=Saab|first3=S.|last4=Brown|first4=K. A.|last5=El-Serag|first5=H. B.|last6=Kim|first6=W. R.|last7=Ahmed|first7=A.|last8=Kugelmas|first8=M.|last9=Gordon|first9=S. C.|date=2014-03-01|title=The impact of hepatitis C burden: an evidence-based approach|journal=Alimentary Pharmacology & Therapeutics|language=en|volume=39|issue=5|pages=518–531|doi=10.1111/apt.12625|pmid=24461160|s2cid=21263906|issn=1365-2036|doi-access=free}}</ref> It has been estimated that a person infected with hepatitis C in the United States will result in a monthly cost of $691.<ref name="Younossi, Kanwal, Saab, et al" /> That number nearly doubles to $1,227 for people with compensated (stable) cirrhosis, while the monthly cost of people with decompensated (worsening) cirrhosis is almost five times as large at $3,682.<ref name="Younossi, Kanwal, Saab, et al" /> The wide-ranging effects of hepatitis make it difficult to estimate indirect costs, but studies have speculated that the total cost is $6.5 billion annually in the United States.<ref name="Udompap, Kim & Kim" /> In Canada, 56% of HCV related costs are attributable to cirrhosis and total expenditures related to the virus are expected to peak at CAD$396 million in the year 2032.<ref>{{Cite journal|last1=Myers|first1=Robert P.|last2=Krajden|first2=Mel|last3=Bilodeau|first3=Marc|last4=Kaita|first4=Kelly|last5=Marotta|first5=Paul|last6=Peltekian|first6=Kevork|last7=Ramji|first7=Alnoor|last8=Estes|first8=Chris|last9=Razavi|first9=Homie|date=2014-05-01|title=Burden of disease and cost of chronic hepatitis C infection in Canada|journal=Canadian Journal of Gastroenterology & Hepatology|volume=28|issue=5|pages=243–250|issn=2291-2797|pmc=4049256|pmid=24839620|doi=10.1155/2014/317623|doi-access=free}}</ref>
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