What are the diagnostic criteria for cirrhosis?

Diagnostic Criteria for Cirrhosis

The most accurate diagnostic approach for cirrhosis combines clinical assessment, laboratory testing, imaging studies, and elastography techniques, with MR elastography currently being the most accurate imaging modality for diagnosis and staging of hepatic fibrosis. 1

Clinical and Laboratory Assessment

• Clinical examination should focus on identifying signs of cirrhosis and portal hypertension, including ascites, spider angiomas, palmar erythema, splenomegaly, jaundice, and dilated abdominal wall veins 2, 3
• Laboratory tests should evaluate liver function, with persistently elevated liver function tests showing significant correlation with underlying hepatic disease 4
• While serum markers exist (aspartate aminotransferase-to-platelet ratio index, FibroTest, FibroSure), they are inaccurate for intermediate stages of fibrosis 1

Imaging Studies

Morphological Features on Conventional Imaging (US, CT, MRI)

• Liver surface nodularity, particularly of the anterior left lobe 1
• Atrophic right lobe with hypertrophied caudate lobe and lateral segment left lobe 1, 2
• Atrophied medial segment left lobe 1
• Right hepatic posterior "notch" 1
• Expanded gallbladder fossa 1
• Narrow hepatic veins (right hepatic vein < 5 mm) 1
• Enlarged caudate-to-right lobe ratio (modified ratio >0.90) 1
• Enlargement of hilar periportal space (>10-mm thickness) 1

Limitations of Conventional Imaging

• Morphological changes are subjective and typically present only in later stages of fibrosis 1
• Even in aggregate, the sensitivity of these features for diagnosis of cirrhosis and non-cirrhotic fibrosis is too low for excluding hepatic fibrosis 1
• Noncontrast CT has limited utility as it relies on gross structural changes present only in very advanced disease 1

Elastography Techniques

Ultrasound Elastography

• Transient elastography (TE, FibroScan) has sensitivity and specificity of 87% and 91% for diagnosing cirrhosis (F4) 1
• Values >15 kPa strongly suggest compensated advanced chronic liver disease (cACLD) 2, 5
• Limitations: not reliable in patients with obesity or ascites; cannot distinguish between intermediate stages of fibrosis 1
• Acoustic radiation force impulse (ARFI) can be combined with conventional US and used in patients with obesity, ascites, and NAFLD 1
• ARFI has lower rates of unreliable examinations compared to TE (2.1% vs 6.6%) 1

MR Elastography

• Currently the most accurate imaging modality for diagnosis and staging of hepatic fibrosis 1, 2
• Compares favorably with US shear wave elastography, especially in patients with obesity 1, 2
• Limitations: reduced accuracy in patients with hepatic iron deposition and at 3T due to susceptibility artifacts 1

Confounding Factors in Elastography

• Liver stiffness measurements can be influenced by:
  • Edema and inflammation 1, 2
  • Extrahepatic cholestasis 1
  • Passive congestion 1
  • Recent meals (patients should be fasting) 1, 2

Liver Biopsy

• Remains the gold standard for diagnosis but has significant limitations 1, 6
• Should be avoided when unnecessary due to:
  • Invasive nature and potential complications 1
  • Sampling errors and observer variability 1, 6
  • Limited acceptance for longitudinal monitoring 1
• Consider biopsy only when:
  • Results of noninvasive evaluation are indeterminate 7
  • Etiology of liver disease remains unknown 7
  • Result may alter management 7
  • Benefit outweighs risk 4

Diagnostic Algorithm

1. Initial evaluation: clinical assessment, laboratory tests, and ultrasound examination 2
2. If initial evaluation suggests cirrhosis, perform elastography (transient elastography or MR elastography) 2
3. Consider contrast-enhanced CT or MRI to better characterize liver morphology 2
4. If results remain indeterminate and diagnosis will impact management, consider liver biopsy 7, 4

Common Pitfalls and Caveats

• Approximately 40% of people with cirrhosis are diagnosed only when they present with complications such as hepatic encephalopathy or ascites 5
• Progression from hepatic fibrosis to compensated cirrhosis to decompensated cirrhosis can be slow and clinically silent 2
• Morphological changes on conventional imaging may not be apparent until very advanced stages of disease 2
• Elastography results can be affected by inflammation, hepatic congestion, and recent meals 2
• No single serologic or radiographic test can accurately diagnose cirrhosis in all cases 4