What labs should be ordered for a patient with asterixis in liver cirrhosis?

From the Guidelines

For a patient with asterixis in liver cirrhosis, the essential laboratory tests to order include blood electrolytes, blood glucose, blood calcium, cell blood count, haemostasis, inflammatory proteins, blood urea, and creatinine, as these are crucial for excluding differential diagnoses and guiding management decisions. According to the French recommendations for the diagnosis and management of hepatic encephalopathy 1, a clinical and paraclinical work-up is necessary to exclude differential or associated diagnoses in cirrhotic patients with neurological disorders. This work-up should include:

• Recent medical history, including infections, trauma, withdrawal, and psychotropic drugs
• Complete medical history, including diabetes, neurovascular diseases, epilepsy, and known complications of cirrhosis and liver failure
• Neurological examination, including cognitive, motor, sensory, neurovisual, and cranial nerve testing, as well as assessment for asterixis
• Common blood tests, such as those mentioned above, to evaluate the patient's metabolic and hematological status
• Brain imaging, preferably MRI, to rule out other causes of neurological symptoms

These tests are essential for identifying potential precipitating factors, guiding treatment decisions, and monitoring response to therapy. The experts suggest that internal standard operating procedures should be established to provide neurological expertise within a suitable time delay 1. By ordering these laboratory tests, clinicians can ensure that patients with asterixis in liver cirrhosis receive prompt and appropriate management, which is critical for improving morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

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From the Research

Labs to Order for Asterixis in Liver Cirrhosis

To approach a patient with asterixis in liver cirrhosis, several laboratory tests and assessments can be useful for diagnosis, management, and prognosis. The following are key considerations:

• Initial Workup:
  • Viral hepatitis serologies 2
  • Ferritin and transferrin saturation 2
  • Abdominal ultrasonography 2
  • Complete blood count (CBC) 2
  • Liver function tests (LFTs), including serum bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT) 3, 4
  • Prothrombin time/international normalized ratio (PT/INR) 2, 3
• Assessment of Liver Fibrosis:
  • Aspartate transaminase to platelet ratio index (APRI) score 2, 5
  • Fibrosis 4 (FIB-4) score 2, 5
  • FibroTest/FibroSure 2
  • Nonalcoholic fatty liver fibrosis score 2
  • Transient elastography 2, 5
• Evaluation of Hepatocellular Injury:
  • Testing for viral hepatitis A, B, and C 4
  • Assessment for nonalcoholic fatty liver disease and alcoholic liver disease 4
  • Screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 4
• Cholestatic Injury Evaluation:
  • Testing for primary biliary cholangitis and primary sclerosing cholangitis if alkaline phosphatase elevation is of hepatic origin 4
• Bilirubin Fractionation:
  • Fractionation of total bilirubin into direct and indirect bilirubin fractions to differentiate between hepatocellular disease and biliary obstruction 4
• Advanced Tests:
  • Indocyanine green plasma clearance 5
  • 13C-aminopyrine breath test 5
  • Liver biopsy may be considered when serologic testing and imaging fail to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible 4

Additional Considerations

• The choice of labs should be guided by the clinical presentation, risk factors, and the need to assess the severity of liver disease and its complications 2, 3, 6.
• Monitoring for complications of cirrhosis, such as varices, ascites, hepatic encephalopathy, and hepatocellular carcinoma, is crucial 2, 6.