What labs should be ordered for a liver cirrhosis workup?

Laboratory Tests for Liver Cirrhosis Workup

A comprehensive liver cirrhosis workup should include serum liver-related tests (bilirubin, alkaline phosphatase, AST, ALT, platelets, prothrombin time), non-invasive fibrosis assessment (elastography and/or ELF test), and appropriate imaging studies. 1

Initial Laboratory Assessment

Essential Blood Tests

• Liver Function Tests:

  • Serum bilirubin (total and direct)
  • Alkaline phosphatase (ALP)
  • Aspartate aminotransferase (AST)
  • Alanine aminotransferase (ALT)
  • Gamma-glutamyl transpeptidase (GGT)
  • Serum albumin
  • Prothrombin time (PT)/International Normalized Ratio (INR)

• Complete Blood Count:

  • Platelet count (thrombocytopenia is common in cirrhosis)
  • White blood cell count
  • Hemoglobin/hematocrit
  • Mean corpuscular volume (MCV) - often elevated in alcoholic liver disease 1

Fibrosis Assessment

• Non-invasive Fibrosis Tests:
  • FIB-4 score (based on age, AST, ALT, and platelet count)
  • APRI (AST to Platelet Ratio Index)
  • Enhanced Liver Fibrosis (ELF) test 1
  • Transient elastography (FibroScan) - cutoff value >12.5 kPa suggests cirrhosis 2

Etiological Workup

Viral Hepatitis

• Hepatitis B serology (HBsAg, anti-HBc, HBeAg/anti-HBe, HBV DNA) 1
• Hepatitis C antibody and HCV RNA if antibody positive 1
• Hepatitis D antibody (if HBsAg positive) 1

Metabolic and Autoimmune Causes

• Fasting blood glucose and HbA1c
• Lipid profile
• Autoimmune markers:
  • Antinuclear antibody (ANA)
  • Anti-smooth muscle antibody (ASMA)
  • Anti-mitochondrial antibody (AMA)
  • Anti-liver kidney microsomal antibody (anti-LKM)
  • Immunoglobulin levels (IgG, IgA, IgM)

Iron Studies

• Serum ferritin
• Transferrin saturation 1

Other Tests

• Alpha-1-antitrypsin level
• Ceruloplasmin (in younger patients to rule out Wilson's disease) 1
• Alpha-fetoprotein (AFP) for hepatocellular carcinoma screening 2

Assessment of Portal Hypertension and Liver Function

• Liver Synthetic Function:

  • Serum albumin
  • PT/INR
  • Bilirubin

• Portal Hypertension Markers:

  • Platelet count
  • Spleen size on imaging

Scoring Systems

• Child-Turcotte-Pugh (CTP) score: Assesses severity using bilirubin, albumin, INR, ascites, and encephalopathy 2
• MELD score: Calculated using bilirubin, creatinine, and INR 2

Imaging Studies

• Ultrasound: First-line imaging to assess liver nodularity, splenomegaly, and screen for hepatocellular carcinoma 2
• MRI/MRCP: Particularly useful for cholestatic liver diseases 1

Special Considerations

• For patients with elevated transaminases and alcohol use, the AST/ALT ratio >2 often suggests alcoholic liver disease 1
• For patients with suspected non-alcoholic fatty liver disease (NAFLD), consider metabolic syndrome markers 1
• For patients with suspected cholestatic disease, consider MRCP to evaluate bile ducts 1

Follow-up Testing

• For patients diagnosed with cirrhosis:
  • Liver function tests every 3-6 months
  • Ultrasound for HCC screening every 6 months 2
  • Upper endoscopy to screen for esophageal varices 1

Common Pitfalls to Avoid

1. Normal liver enzymes do not rule out cirrhosis - advanced fibrosis can be present with normal transaminases 1
2. Relying solely on liver function tests - they can be normal in early cirrhosis 2
3. Missing concomitant liver diseases - approximately 20% of patients with alcohol-related liver disease have a co-existing etiology 1
4. Failing to assess for complications - all cirrhotic patients need screening for varices and hepatocellular carcinoma 2

Remember that liver biopsy remains the gold standard for diagnosis but is increasingly being replaced by non-invasive methods due to its invasive nature and potential complications 2. Consider liver biopsy when non-invasive tests are inconclusive or when a competing liver disease is suspected.