What is the recommended workup and management for a patient with suspected cirrhosis?

Recommended Workup and Management for Suspected Cirrhosis

The diagnostic workup for suspected cirrhosis should include liver function tests, complete blood count, coagulation studies, abdominal ultrasound, and non-invasive fibrosis assessment, followed by targeted testing for the underlying etiology. 1

Initial Diagnostic Evaluation

Laboratory Testing

• Liver function tests: ALT, AST, GGT, alkaline phosphatase, bilirubin, albumin
• Complete blood count: Look for thrombocytopenia (suggests portal hypertension)
• Coagulation studies: PT/INR (assesses synthetic liver function)
• Serum electrolytes, creatinine, BUN: Baseline renal function
• Etiology-specific testing:
  • Viral hepatitis serologies (HBV, HCV)
  • Iron studies (ferritin, transferrin saturation)
  • Autoimmune markers (ANA, ASMA, immunoglobulins)
  • Alpha-1 antitrypsin
  • Ceruloplasmin (in younger patients)

Non-invasive Fibrosis Assessment

• Transient elastography (FibroScan): Values ≥15 kPa typically confirm cirrhosis 2
• Serum-based fibrosis scores:
  • APRI (AST to Platelet Ratio Index)
  • FIB-4 score
  • ALD/NAFLD index (based on MCV, AST/ALT ratio, BMI, gender) 1

Imaging

• Abdominal ultrasound: First-line imaging to assess liver morphology, splenomegaly, and screen for ascites 1
• Cross-sectional imaging (CT/MRI): Consider if ultrasound is inconclusive or to evaluate for hepatocellular carcinoma

Diagnostic Paracentesis

If ascites is present, a diagnostic paracentesis is strongly recommended to:

• Calculate the serum-ascites albumin gradient (SAAG) 1
• Rule out spontaneous bacterial peritonitis (SBP) 1
• Perform cell count, culture, total protein, and other tests based on clinical suspicion 1

Paracentesis Indications:

• All patients with new-onset ascites 1
• All cirrhotic patients with ascites on hospital admission 1
• Patients with GI bleeding, fever, abdominal pain, hepatic encephalopathy, or worsening liver/renal function 1

Liver Biopsy Considerations

Liver biopsy should be considered when:

• Non-invasive testing is inconclusive
• Multiple potential etiologies exist
• Competing liver diseases are suspected
• The result would alter management

However, biopsy carries approximately 2% risk of severe complications and should be performed with imaging guidance 1

Management of Cirrhosis

General Measures

• Salt restriction: 5-6.5g daily (no added salt diet) 1
• Alcohol abstinence: Complete cessation regardless of etiology 1
• Nutritional counseling: Regarding sodium content in diet 1
• Medication review: Avoid hepatotoxic medications

Screening for Complications

Varices Screening

• Upper endoscopy to screen for esophageal varices
• Can be deferred if platelets >150,000 and FibroScan <20 kPa (Baveno criteria) 1

Hepatocellular Carcinoma Screening

• Ultrasound every 6 months 3, 2
• Consider alpha-fetoprotein as adjunct

Management of Complications

Ascites

• Salt restriction (5-6.5g/day) and diuretics 1
• Consider combination aldosterone antagonist and loop diuretics 2
• Diagnostic paracentesis if worsening or new-onset 1

Spontaneous Bacterial Peritonitis (SBP)

• Diagnose with ascitic fluid neutrophil count >250/mm³ 1
• Immediate empirical antibiotics (cefotaxime widely studied) 1
• Consider albumin infusion for patients with renal dysfunction 1, 4
• Secondary prophylaxis with norfloxacin, ciprofloxacin, or co-trimoxazole after recovery 1

Hepatic Encephalopathy

• Identify and treat precipitating factors (infection, GI bleeding, electrolyte imbalances) 1
• Lactulose as first-line therapy 2
• Add rifaximin for recurrent episodes 5
• Brain imaging only for differential diagnosis 1

Variceal Bleeding

• Prophylaxis with non-selective beta-blockers (carvedilol or propranolol) 1, 2
• Endoscopic band ligation for high-risk varices 1
• In acute bleeding: resuscitation, antibiotics, vasoactive drugs, and urgent endoscopy 1

Monitoring and Follow-up

• Regular assessment of liver function and calculation of prognostic scores (Child-Pugh, MELD) every 6 months 6
• Ultrasound surveillance for hepatocellular carcinoma every 6 months 3, 2
• Consider liver transplant evaluation for:
  • Decompensated cirrhosis
  • MELD score ≥15
  • Hepatocellular carcinoma 6

Common Pitfalls to Avoid

• Delaying diagnostic paracentesis when ascites is present
• Failing to screen for varices and hepatocellular carcinoma
• Overlooking non-hepatic manifestations of cirrhosis (e.g., renal dysfunction)
• Missing concomitant etiologies of liver disease (present in ~20% of patients) 1
• Inappropriate use of proton pump inhibitors, which may increase SBP risk 1

By following this structured approach to diagnosis and management, patients with cirrhosis can receive appropriate care to prevent complications, improve quality of life, and potentially reverse early cirrhosis through management of the underlying cause.