From the Guidelines
The initial laboratory evaluation for new onset cirrhosis should include bilirubin, albumin, ALT, ALP, and GGT, together with a full blood count if not already performed within the previous 12 months. This recommendation is based on the guidelines on the management of abnormal liver blood tests published in the journal Gut in 2018 1. The initial investigation should focus on assessing liver function and identifying potential causes of liver disease.
Key Components of Initial Evaluation
- Bilirubin: to assess for jaundice and liver dysfunction
- Albumin: to evaluate synthetic liver function
- ALT and ALP: to assess for hepatocellular injury and cholestasis
- GGT: to evaluate for liver disease and alcohol use
- Full blood count: to assess for anemia, thrombocytopenia, and leukopenia, which can be associated with cirrhosis
In addition to these tests, the AST to ALT ratio should be calculated to assess the risk of significant fibrosis, as an AST:ALT ratio of >1 indicates advanced fibrosis/cirrhosis 1. This can be done by reflex testing of AST (or ALT) on the same sera following the detection of an abnormal ALT or GGT.
Additional Testing
Further testing may be necessary to determine the etiology of cirrhosis and to evaluate for complications, but the initial evaluation should focus on the recommended tests outlined above. It is essential to note that both AST and ALT can be normal even in the setting of cirrhosis, highlighting the importance of a comprehensive evaluation 1.
From the Research
Laboratory Evaluation for New Onset Cirrhosis
The laboratory evaluation for new onset cirrhosis involves a series of tests to assess liver function and damage. The following are some of the key tests and markers used in the evaluation:
- Viral hepatitis serologies to identify the underlying cause of cirrhosis 2
- Ferritin and transferrin saturation to assess iron overload 2
- Abdominal ultrasonography to evaluate liver morphology and detect any complications such as varices or ascites 2
- Complete blood count (CBC) to assess for anemia, thrombocytopenia, or leukopenia 2
- Liver function tests (LFTs) including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin to assess liver damage and function 2, 3, 4, 5
- Prothrombin time/international normalized ratio (PT/INR) to assess coagulation function 2
- Non-invasive tests such as the aspartate transaminase to platelet ratio index (APRI) score, Fibrosis 4 (FIB-4) score, and transient elastography to assess liver fibrosis 2, 6
Biomarkers and Serum Tests
Biomarkers and serum tests can be used to evaluate liver damage and synthetic function. The ratio of AST to ALT has been shown to be a useful predictor of cirrhosis, with a ratio of ≥1 indicating a higher likelihood of cirrhosis 3, 4, 5. The APRI score and FIB-4 score are also useful in assessing liver fibrosis and can help identify patients with advanced liver disease 2, 6.
Imaging Techniques
Imaging techniques such as ultrasonography and transient elastography can be used to assess liver morphology and detect any complications such as varices or ascites 2, 6. These tests can also help evaluate liver fibrosis and stiffness, which can be indicative of cirrhosis.
Monitoring and Management
Regular monitoring and management of patients with cirrhosis are crucial to prevent complications and improve outcomes. This includes regular LFTs, CBC, and PT/INR, as well as ultrasound monitoring for varices and hepatocellular carcinoma 2. Patients with cirrhosis should also receive directed counseling, laboratory testing, and ultrasound monitoring to prevent decompensation and death 2.