for Health Care Providers
How to Diagnose Cirrhosis - Cirrhosis
Identifying the presence of cirrhosis is essential in any patient with chronic liver disease. Making the diagnosis of cirrhosis will affect management and follow-up.
Key concepts
- Cirrhosis is the end stage of any chronic liver disease, such as hepatitis B, hepatitis C, complications of alcohol use disorder, and others
- The gold standard for diagnosis is by histology: Liver biopsy sample shows the architecture of the liver is distorted by regenerative nodules surrounded by fibrous tissue
- A diagnosis of cirrhosis can sometimes be made without a liver biopsy, using clinical findings
- There are 2 clinical stages of cirrhosis: compensated and decompensated
- Compensated cirrhosis is the asymptomatic stage; therefore, a clinical diagnosis is more difficult to make, and a liver biopsy may be needed
- Decompensated cirrhosis is the symptomatic stage and is characterized by the presence or development of ascites, variceal hemorrhage, or hepatic encephalopathy; making the diagnosis is not challenging, and a liver biopsy is rarely required
Key recommendations
- Cirrhosis should be investigated in patients with chronic (>6 months in duration) abnormalities in liver enzymes and/or in patients in whom risk factors for cirrhosis are present: alcohol use disorder, hepatitis C, hepatitis B, obesity, and metabolic syndrome (even in the absence of liver enzyme abnormalities)
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The following can help support the diagnosis of cirrhosis:
- Careful physical exam
- Appropriate laboratory tests
- Appropriate imaging tests
- Liver stiffness measurements
- However, physical exam, laboratory tests, and radiology tests (clinical findings) all may yield entirely normal results in a patient with compensated cirrhosis
- Liver biopsy (an invasive method) is required to establish (or exclude) the diagnosis of cirrhosis when there is high suspicion but absence of non-invasive findings
Physical exam findings suggestive of cirrhosis:
- Bitemporal muscle wasting
- Stigmata of chronic liver disease (palmar erythema, vascular spiders)
- Palpable left lobe of the liver (in the epigastrium)
- Small liver span (right lobe: normal is approximately 9 cm)
- Abdominal collaterals (caput medusae)
- Splenomegaly
- Ascites (shifting dullness)
- Asterixis
Laboratory findings suggestive of cirrhosis:
- Platelet count < 180,000
- Albumin < 3.8 mg/dL
- AST > ALT (in non-alcoholic etiologies)
- INR > 1.2
- Bilirubin > 1.5 mg/dL (very non-specific)
- FIB-4
or APRI
scores calculated using age, AST, ALT, and/or platelet count
Imaging findings (abdominal ultrasound, CT, or MRI) suggestive of cirrhosis:
- Nodular surface of the liver
- Splenomegaly
- Collaterals
- Enlarged caudate lobe/left lobe of the liver
- Shrunken right lobe of the liver
- Ascites
Elastographic findings suggestive of cirrhosis:
- Transient elastography (Fibroscan®) is a point-of-care method to measure liver stiffness
- Most useful for excluding cirrhosis
- Cutoffs are different for different etiologies of cirrhosis
- Other methods to measure liver stiffness include acoustic radiation force impulse (ARFI) and magnetic resonance elastography (MRE), but they are not point-of-care