Diagnosis of cirrhosis

OVERVIEW ㅡ 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. 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 and 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.

INVESTIGATIONS

Table (1). Investigation of cirrhosis
TYPE	FINDING
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) Fibrosis-4 (FIB-4) Index for Liver Fibrosis or AST to Platelet Ratio Index (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 and 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

REFERENCES

• Cirrhosis: Diagnosis and Management. [online] Available at: https://www.aafp.org/afp/2019/1215/p759.html

  How to Diagnose Cirrhosis - Viral Hepatitis and Liver Disease. [online] Available at: https://www.hepatitis.va.gov/cirrhosis/background/how-to-diagnose.as