From the Guidelines
The workup for liver cirrhosis should start with a comprehensive approach including laboratory tests and imaging to confirm the diagnosis, determine the cause, assess severity, and identify complications, as recommended by the American College of Radiology Appropriateness Criteria 1. The initial evaluation should include a complete blood count, comprehensive metabolic panel (focusing on liver enzymes, albumin, and bilirubin), coagulation studies (PT/INR), and viral hepatitis serologies (HBV, HCV). Additional testing should include:
- Autoimmune markers (ANA, anti-smooth muscle antibody, immunoglobulins)
- Iron studies (ferritin, transferrin saturation)
- Ceruloplasmin
- Alpha-1 antitrypsin levels
- Lipid profiles depending on suspected etiology Imaging is essential, starting with abdominal ultrasound with Doppler to assess liver texture, size, and portal flow, followed by transient elastography (FibroScan) to quantify fibrosis, as elastography-based ultrasound and MRI techniques are more useful for assessment of precirrhotic hepatic fibrosis 1. In some cases, CT or MRI may be needed for better visualization, especially in patients with severe steatosis or obesity, where multiphase CT or MRI may have a role in surveillance for hepatocellular carcinoma (HCC) 1. Definitive diagnosis often requires liver biopsy, though this may be avoided if clinical, laboratory, and imaging findings are conclusive. Disease severity should be assessed using scoring systems like Child-Pugh or MELD. Endoscopy is recommended to screen for esophageal varices in all newly diagnosed patients, as part of the assessment of portal hypertension 2. This comprehensive workup is necessary because cirrhosis represents end-stage liver disease with fibrosis and nodular regeneration that disrupts normal liver architecture and function, leading to potential complications like portal hypertension, ascites, and hepatic encephalopathy. The diagnosis of hepatocellular carcinoma (HCC) in patients with liver cirrhosis can be made using non-invasive imaging criteria, including dynamic (multiple phase) MRI or CT studies, which can identify the typical vascular hallmark of HCC (hypervascular in the arterial phase with washout in the portal venous or delayed phases) 2. In patients with advanced fibrosis at risk for HCC, ultrasound is the surveillance modality recommended by international guidelines in nearly all circumstances 1.
From the Research
Liver Cirrhosis Workup
- The initial workup for liver cirrhosis includes viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography, as well as complete blood count, liver function tests, and prothrombin time/international normalized ratio 3.
- Additional testing is based on demographics and risk factors, and may include serum and ultrasound-based screening tests to assess fibrosis, such as the aspartate transaminase to platelet ratio index score, Fibrosis 4 score, and transient elastography 3, 4.
- Liver function tests, such as serum bilirubin, liver enzymes, and serum albumin, can partly assess liver function, but there is no single test that can evaluate all functions of the liver 5.
- Coagulation testing, including global tests of clot formation, can provide practical information to clinicians and help guide decision making in patients with liver disease 6.
- In patients with cirrhosis, routine laboratory tests for primary hemostasis and coagulation may show anomalies, but primary hemostasis and thrombin production do not appear to be decreased, particularly when the platelet count is above 75,000/μl 7.
Diagnostic Tests
- Viral hepatitis serologies
- Ferritin
- Transferrin saturation
- Abdominal ultrasonography
- Complete blood count
- Liver function tests
- Prothrombin time/international normalized ratio
- Aspartate transaminase to platelet ratio index score
- Fibrosis 4 score
- Transient elastography
- Serum bilirubin
- Liver enzymes
- Serum albumin
Management
- Directed counseling
- Laboratory testing
- Ultrasound monitoring
- Treatment goals: preventing cirrhosis, decompensation, and death
- Varices: monitored with endoscopy and often require prophylaxis with nonselective beta blockers
- Ascites: treatment includes diuresis, salt restriction, and antibiotic prophylaxis for spontaneous bacterial peritonitis, when indicated
- Hepatic encephalopathy: managed with lifestyle and nutritional modifications and, as needed, with lactulose and rifaximin
- Hepatocellular carcinoma screening: includes ultrasound screening every six months for patients with cirrhosis 3