From the Guidelines
For a patient presenting with nearly all symptoms of cirrhosis, including ascites, spider angioma, gynaecomastia, and palmar erythema, the most appropriate diagnostic test is Liver Stiffness (LS) by transient elastography (TE; FibroScan), as it has proven to be very accurate for discriminating patients with and without clinically significant portal hypertension (CSPH), with a mean area under the receiver operating curve (AUROC) of 0.93 1.
When evaluating a patient with suspected cirrhosis, it is essential to consider the most recent and highest quality evidence. The 2017 practice guidance by the American Association for the Study of Liver Diseases 1 recommends a step-wise diagnostic approach, starting with physical examination and laboratory data, including platelet count. However, the combination of platelet count with other noninvasive tests, such as ultrasound and liver stiffness measurement, improves the diagnosis of CSPH.
Key points to consider in the diagnostic workup of cirrhosis include:
- Physical examination signs, such as spider nevi or visible abdominal portosystemic collaterals, which cannot be used to rule out CSPH 1
- Laboratory data, including platelet count, which correlates slightly with hepatic venous pressure gradient (HVPG) and the presence of gastroesophageal varices (GEV), but is not accurate enough to diagnose or exclude CSPH or GEV on its own 1
- Imaging studies, such as ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI), which can provide evidence of morphological abnormalities associated with cirrhosis and PH, including portocollateral circulation and reversal of flow within the portal system 1
- Liver stiffness measurement by transient elastography (TE; FibroScan), which has been shown to be very accurate for discriminating patients with and without CSPH, with a mean AUROC of 0.93 1
In contrast to liver biopsy, which is considered the gold standard for definitive diagnosis of cirrhosis, liver stiffness measurement by TE is a noninvasive test that can provide accurate information on the presence of CSPH and varices, without the risks associated with invasive procedures. Therefore, liver stiffness measurement by TE should be considered the first-line diagnostic test for patients presenting with symptoms of cirrhosis, including ascites, spider angioma, gynaecomastia, and palmar erythema 1.
From the Research
Diagnostic Tests for Cirrhosis
The patient's symptoms, including ascites, spider angioma, gynaecomastia, and palmar erythema, are indicative of cirrhosis. To diagnose cirrhosis, several tests can be used, including:
- Liver biopsy, which is considered the gold standard for diagnosing cirrhosis 2
- Endoscopic ultrasound (EUS), which can be used to diagnose and manage complications of cirrhosis, such as esophageal varices 3, 4
- Ultrasonography (US), which can be used to assess liver morphology and detect signs of portal hypertension 5, 6
- Doppler ultrasound, which can be used to measure portal vein velocity and predict the presence of esophageal varices 5
Non-Invasive Diagnostic Tests
Non-invasive diagnostic tests, such as ultrasonography and Doppler ultrasound, can be used to diagnose cirrhosis and portal hypertension. These tests are safe, easy to perform, and inexpensive, making them useful for primary care centers 6. The following parameters can be used to diagnose cirrhosis using ultrasonography:
- Liver size and morphology
- Spleen size
- Bluntness of the liver edge
- Nodularity of the liver surface
- Coarseness of the liver parenchyma
Invasive Diagnostic Tests
Invasive diagnostic tests, such as liver biopsy and endoscopic ultrasound, can provide more accurate diagnoses and can be used to manage complications of cirrhosis. However, these tests are associated with risks and complications, such as bleeding and infection 2. The following invasive diagnostic tests can be used to diagnose cirrhosis:
- Percutaneous liver biopsy
- Transjugular liver biopsy
- Endoscopic ultrasound-guided liver biopsy 3