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Viral Hepatitis and Liver Disease

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How to Diagnose Cirrhosis

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)
  • 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-4Link will take you outside the VA website. VA is not responsible for the content of the linked site. or APRILink will take you outside the VA website. VA is not responsible for the content of the linked site. 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