Laboratory Evaluation for Jaundice in Cirrhosis
For a cirrhotic patient presenting with yellowish sclera (jaundice), order a comprehensive panel including: total and direct bilirubin, AST, ALT, alkaline phosphatase, GGT, albumin, INR/PT, complete blood count with platelets, and creatinine. 1, 2
Essential Initial Laboratory Tests
Core Liver Function Panel
- Total and direct (conjugated) bilirubin are essential to confirm hyperbilirubinemia and distinguish conjugated from unconjugated causes, with bilirubin being the single best test of overall liver function and a critical prognostic marker in cirrhosis 1, 2
- AST and ALT help track hepatocellular injury trends, though these may be normal or near-normal even in advanced cirrhosis 2, 3
- Alkaline phosphatase and GGT assess for cholestatic patterns and help distinguish hepatocellular from biliary causes of jaundice 4, 1
Synthetic Function Assessment
- Albumin reflects hepatic synthetic function and is a critical component of Child-Pugh and MELD prognostic scoring systems 2, 5
- Prothrombin time/INR assesses coagulation factor synthesis, though interpretation requires caution in cirrhosis due to rebalanced hemostasis 2, 5
Additional Critical Tests
- Complete blood count with platelet count monitors for thrombocytopenia from splenic sequestration and serves as a surrogate marker for portal hypertension (platelet count <150,000/mm³ suggests clinically significant portal hypertension) 2
- Creatinine and calculated GFR are essential as renal dysfunction affects prognosis and is incorporated into MELD score 2
Etiology-Specific Testing
Standard Liver Aetiology Screen
If the cause of cirrhosis is unknown or jaundice represents acute decompensation, consider a liver aetiology screen including: 4
- Hepatitis B surface antigen
- Hepatitis C antibody (with PCR if positive)
- Anti-mitochondrial antibody
- Anti-smooth muscle antibody
- Antinuclear antibody
- Serum immunoglobulins
- Simultaneous serum ferritin and transferrin saturation
Special Considerations for Acute Decompensation
- If acute liver failure is suspected with hemolysis, check serum copper (typically >200 μg/dL in Wilson disease), 24-hour urinary copper, and ceruloplasmin, as Wilson disease presents with Coombs-negative hemolysis, modest aminotransferase elevations, and alkaline phosphatase to bilirubin ratio <2 4
Prognostic Scoring
Calculate Child-Pugh and MELD scores using the laboratory values obtained, as these incorporate bilirubin, albumin, INR, and creatinine to assess disease severity, prognosis, and transplant candidacy 2, 5
Critical Pitfalls to Avoid
- Do not assume normal or near-normal transaminases exclude significant liver disease - AST and ALT correlate poorly with fibrosis stage and may remain within normal range even in advanced cirrhosis 3
- Do not rely solely on PT/INR for bleeding risk assessment - cirrhosis creates a rebalanced hemostatic state, and traditional coagulation tests are inadequate for predicting bleeding 2
- Bilirubin, albumin, and INR are superior markers of hepatic synthetic capacity and prognosis compared to transaminases 2, 5