From the Guidelines
Diagnosing liver cirrhosis involves a combination of medical history, physical examination, blood tests, and imaging studies, with the most recent evidence suggesting that ultrasound and non-invasive alternatives like transient elastography are crucial for diagnosis and monitoring. The diagnostic process begins with a thorough medical history and physical examination to identify risk factors like alcohol use, viral hepatitis, or metabolic disorders. Blood tests are essential, including liver function tests (ALT, AST, alkaline phosphatase, bilirubin), complete blood count, albumin levels, and coagulation studies to assess liver function. Specific tests for underlying causes such as hepatitis B and C viral markers, autoimmune markers, iron studies, and alpha-1 antitrypsin levels should be performed 1.
Imaging studies are crucial, with ultrasound typically being the first choice, as it is recommended by international guidelines for screening for hepatocellular carcinoma (HCC) in patients with cirrhosis 1. Ultrasound can diagnose cirrhosis, but it has limited utility for assessing earlier stages of fibrosis. Non-invasive alternatives like transient elastography (FibroScan), which measures liver stiffness, and serum biomarker panels like FibroTest or APRI can also be used for diagnosis and monitoring 1.
The gold standard for diagnosis is liver biopsy, where a small tissue sample is examined microscopically to confirm cirrhosis, determine its severity, and identify the underlying cause. However, liver biopsy is not an ideal method for diagnosis because it is disliked by patients, has complications, and is plagued by sampling errors 1. Once diagnosed, patients should undergo screening for complications such as esophageal varices via endoscopy and hepatocellular carcinoma through regular ultrasound and alpha-fetoprotein testing.
Key steps in the diagnosis of liver cirrhosis include:
- Medical history and physical examination
- Blood tests, including liver function tests and specific tests for underlying causes
- Imaging studies, starting with ultrasound
- Non-invasive alternatives like transient elastography
- Liver biopsy, if necessary
- Screening for complications like esophageal varices and hepatocellular carcinoma. Early diagnosis is critical as it allows for management of underlying causes and prevention of further liver damage, even though cirrhosis itself is irreversible 1.
From the Research
Diagnosing Liver Cirrhosis
To diagnose liver cirrhosis, several steps can be taken:
- Initial workup 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
- Common serum and ultrasound-based screening tests to assess fibrosis include the aspartate transaminase to platelet ratio index score, Fibrosis 4 score, FibroTest/FibroSure, nonalcoholic fatty liver fibrosis score, standard ultrasonography, and transient elastography 2, 3
- Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater 4
- Liver biopsy may be considered only after a thorough, non-invasive serologic and radiographic evaluation has failed to confirm a diagnosis of cirrhosis 5
Non-Invasive Diagnostic Methods
Non-invasive methods for diagnosing liver cirrhosis and portal hypertension include:
- Physical examination
- Laboratory parameters
- Transient elastography
- Doppler-US
- CT scan and MRI (less commonly employed)
- MR elastography and acoustic radiation force imaging (ARFI) (currently under evaluation) 3
- Biomarkers and validated serum tests to evaluate liver damage and synthetic function 6
- Non-invasive imaging techniques, such as basic ultrasound to elastography, to reduce the need for liver biopsy 6
Importance of Early Diagnosis
Early diagnosis of liver cirrhosis can help improve patient outcomes 6
- Careful monitoring, prescribing, and appropriate specialist referral are key considerations in cirrhosis management
- Patients with cirrhosis experience symptoms including muscle cramps, pruritus, poor-quality sleep, and sexual dysfunction, which can be treated 4