What lab work is recommended to evaluate cirrhosis?

Laboratory Evaluation of Cirrhosis

Core Initial Laboratory Panel

All patients being evaluated for cirrhosis should undergo a comprehensive hepatic function panel including bilirubin, AST, ALT, alkaline phosphatase, albumin, PT/INR, platelet count, complete blood count, and renal function tests (BUN and creatinine). 1

Essential Baseline Tests

• Bilirubin (total and conjugated): Elevated conjugated bilirubin indicates advanced disease or biliary obstruction; critical for Child-Pugh and MELD scoring 2, 1
• AST and ALT: Typically elevated in active liver injury, with AST/ALT ratio often >1 in cirrhosis 2, 1
• Alkaline phosphatase: May be elevated, particularly in cholestatic liver disease 2, 1
• GGT: Useful for detecting hepatobiliary involvement and calculating fibrosis indices 2, 1
• Albumin: Decreased levels indicate impaired synthetic function and are essential for Child-Pugh scoring 2, 1
• PT/INR: Prolonged values reflect impaired hepatic synthetic function and are critical for both Child-Pugh and MELD scoring 2, 1
• Platelet count: Thrombocytopenia suggests portal hypertension and is a surrogate marker for advanced disease; also used to calculate APRI and FIB-4 scores 2, 1
• Creatinine and BUN: Essential for MELD score calculation and detecting hepatorenal syndrome; creatinine is an established prognostic marker 2, 1

Etiologic Workup

Once cirrhosis is suspected, determine the underlying cause through targeted serologic testing. 2, 1

Mandatory Screening Tests

• Hepatitis B panel: HBsAg, hepatitis B surface antibody, HBcAb, HBcAb IgM (only in acute hepatitis) 2, 1
• Hepatitis C antibody: Confirm viral load in all positive cases to guide antiviral therapy 2, 1
• Ferritin and transferrin saturation: Screen for hemochromatosis 2, 1

Additional Tests Based on Clinical Context

• Autoimmune markers: Consider if etiology remains unclear despite negative viral and metabolic workup 2, 1
• Alpha-1 antitrypsin level: Screen for alpha-1 antitrypsin deficiency 2, 1
• Ceruloplasmin: Consider for Wilson disease, particularly in younger patients 2, 1

Non-Invasive Fibrosis Assessment

Calculate fibrosis indices using readily available laboratory values to assess disease severity without biopsy. 1

• FIB-4 score: Uses age, AST, ALT, and platelet count 1
• APRI (AST to Platelet Ratio Index): Uses AST and platelet count 1
• GPR (GGT to Platelet Ratio): Uses GGT and platelet count 1

These scores help stratify patients for further evaluation with elastography or specialist referral. 2

Prognostic Scoring Systems

Perform Child-Pugh and MELD score calculations every 6 months for patients with established cirrhosis. 2, 1

Child-Pugh Score Components

• Serum albumin
• Bilirubin
• PT/INR
• Clinical assessment of ascites and encephalopathy 2

MELD Score Components

• Serum bilirubin
• Creatinine
• INR 2

The MELD score ranges from 6 (less ill) to 40 (gravely ill) and was originally designed to assess mortality risk; scores ≥15 warrant liver transplantation evaluation. 2, 3

Albumin-Bilirubin (ALBI) Grade

• Uses serum albumin and bilirubin levels
• Particularly helpful in predicting survival in patients with stable decompensated cirrhosis 2

Portal Hypertension Assessment

Evaluate for clinical signs of portal hypertension through laboratory surrogates. 2

• Thrombocytopenia: Platelet count <150,000 suggests clinically significant portal hypertension 2
• White blood cell count: May be decreased due to hypersplenism 2
• Splenomegaly on imaging: Correlates with portal hypertension 2

Ascites-Specific Testing

When ascites is present or develops, perform diagnostic paracentesis immediately without delay to rule out spontaneous bacterial peritonitis (SBP). 1

Mandatory Ascitic Fluid Tests

• Cell count with differential: Absolute neutrophil count ≥250 cells/mm³ indicates SBP 1
• Ascitic fluid total protein: Helps classify ascites type 1
• Serum-ascites albumin gradient (SAAG): SAAG ≥1.1 g/dL indicates portal hypertension 1
• Ascitic fluid culture: Inoculate blood culture bottles at bedside 1

Additional Tests Based on Clinical Suspicion

• Cytology (if malignancy suspected)
• Amylase (if pancreatic ascites suspected)
• BNP (if cardiac ascites suspected)
• Adenosine deaminase (if tuberculous peritonitis suspected) 1

Monitoring Schedule

For patients with established cirrhosis, perform clinical assessment with laboratory tests every 6 months. 1, 3

This includes:

• Complete hepatic function panel
• Child-Pugh score calculation
• MELD score calculation
• Albumin-bilirubin grade
• Ultrasound surveillance for hepatocellular carcinoma 1

Critical Pitfalls to Avoid

Do not use high thresholds for liver enzyme abnormalities; delayed diagnosis occurs when waiting for values >1.5-2× upper limit of normal. 1

• Use age and sex-normative values for interpretation 1
• Persistent abnormalities over 3-6 months warrant further evaluation even if mildly elevated 1
• Perform screening during clinical stability to avoid transient elevations from acute illness 1
• Normal liver blood tests do not rule out advanced fibrosis or cirrhosis—consider elastography in high-risk patients even with normal labs 2

Limitations of Standard Coagulation Tests

Traditional coagulation tests (PT, INR, aPTT) are inadequate and often misleading in cirrhosis because they only partially evaluate hemostasis and neglect counterbalanced factors. 2

• These tests systematically underestimate coagulation capacity in cirrhosis 2
• Global tests like thromboelastography (TEG) or rotational thromboelastometry (ROTEM) show that patients with cirrhosis often have normal to elevated thrombin-generating capacity 2
• Do not use PT/INR alone to assess bleeding risk before procedures 2

When to Consider Liver Biopsy

Liver biopsy is not generally recommended for all patients with suspected cirrhosis but should be considered when non-invasive test results are inconclusive or when suspicion exists for competing liver disease. 2

Approximately 20% of patients with alcohol use disorder and abnormal liver tests have a co-existing etiology of liver disease. 2 Biopsy carries approximately 2% risk of severe complications including intrahepatic bleeding and pneumothorax. 2