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)
• 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