What is the workup for new onset cirrhosis (liver scarring)?

From the Guidelines

The initial workup for new onset cirrhosis should include a comprehensive evaluation to determine the etiology, assess disease severity, and screen for complications, as outlined in the most recent guidelines 1. The workup should begin with a complete history and physical examination, focusing on risk factors like alcohol use, viral hepatitis exposure, metabolic syndrome, and family history of liver disease.

• Laboratory tests should include:
  • Liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin)
  • Complete blood count
  • Coagulation studies (PT/INR)
  • Albumin
  • Renal function tests
• Specific etiologic testing should include:
  • Hepatitis B and C serology
  • Iron studies (ferritin, transferrin saturation)
  • Autoimmune markers (ANA, ASMA, immunoglobulins)
  • Ceruloplasmin (for Wilson's disease)
  • Alpha-1 antitrypsin levels
  • Lipid profile Imaging studies are essential, with ultrasound being the first-line option to assess liver morphology, identify portal hypertension signs, and screen for hepatocellular carcinoma, as recommended by the British Society of Gastroenterology and the British Association for the Study of the Liver 1.
• Transient elastography (FibroScan) can non-invasively assess fibrosis severity.
• Calculate prognostic scores like MELD and Child-Pugh to determine disease severity.
• Endoscopy should be performed to screen for esophageal and gastric varices. In cases where the etiology remains unclear after non-invasive testing, liver biopsy may be necessary for definitive diagnosis, and the patient should be managed according to the latest clinical practice guidelines for the management of patients with decompensated cirrhosis 1. This comprehensive approach allows for appropriate management strategies to be implemented early, potentially slowing disease progression and preventing complications, and improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Initial Workup for New Onset Cirrhosis

• The initial workup for new onset cirrhosis includes viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography as well as complete blood count, liver function tests, and prothrombin time/international normalized ratio, if not already ordered 2.
• Additional testing is based on demographics and risk factors, and may include serum and ultrasound-based screening tests to assess fibrosis, such as the aspartate transaminase to platelet ratio index score, Fibrosis 4 score, FibroTest/FibroSure, nonalcoholic fatty liver fibrosis score, standard ultrasonography, and transient elastography 2.

Diagnosis and Management of Cirrhosis

• Cirrhosis can be diagnosed by liver biopsy, but may also be diagnosed noninvasively using elastography, a noninvasive assessment of liver stiffness measured in kilopascals, which can typically confirm cirrhosis at levels of 15 kPa or greater 3.
• The management of cirrhosis includes directed counseling, laboratory testing, and ultrasound monitoring, with treatment goals of preventing cirrhosis, decompensation, and death 2.
• Common complications of cirrhosis include varices, ascites, hepatic encephalopathy, and hepatocellular carcinoma, which require monitoring and treatment with medications such as nonselective beta blockers, lactulose, and rifaximin 2, 3.

Symptom Management in Patients with Cirrhosis

• Symptom management in patients with cirrhosis can be challenging, but may include treatment of liver-specific symptoms such as ascites, hepatic encephalopathy, pruritus, and muscle cramping, as well as generalized symptoms such as pain, depression/anxiety, appetite, and fatigue 4.
• Medication management is complex in this population due to altered metabolism of drugs, and requires careful consideration of the potential benefits and risks of different medications 4.

Assessment of Liver Function in Cirrhosis

• The assessment of liver function in cirrhosis should include evaluation of both hepatic and non-hepatic tissue, as well as haemodynamic assessment of portal hypertension 5.
• Commonly available tests such as serum bilirubin, liver enzymes, serum alkaline phosphatase, gamma glutamyl transpeptidase, serum albumin, and prothrombin time can provide some information about liver function, but have limitations 5.
• More advanced tests such as indocyanine clearance tests, methacetin breath test, transient elastography, and MRI-based scans may provide more detailed information about liver function and portal hypertension, but may not be widely available 5.