What are the key signs and evaluation steps for a patient with suspected liver disease, including stigmata and initial laboratory tests?

Stigmata of Liver Disease: Clinical Signs and Evaluation

Physical Examination Findings

The most reliable physical stigmata for detecting cirrhosis are ascites (LR 7.2), spider nevi (LR 4.3), and splenomegaly, while the absence of hepatomegaly helps exclude cirrhosis (LR 0.37). 1

High-Yield Physical Signs

• Ascites is the single most powerful physical finding for cirrhosis, with a likelihood ratio of 7.2 (95% CI, 2.9-12), making it highly specific when present 1
• Spider nevi (spider angiomas) increase the likelihood of cirrhosis with a likelihood ratio of 4.3 (95% CI, 2.4-6.2) 1
• Palmar erythema is commonly associated with chronic liver disease, though specific likelihood ratios are less well-established 1
• Jaundice (icterus) indicates hyperbilirubinemia and suggests advanced liver dysfunction 2
• Splenomegaly suggests portal hypertension and likely cirrhosis, particularly when accompanied by thrombocytopenia 3
• Hepatomegaly presence is less informative, but its absence lowers the likelihood of cirrhosis (LR 0.37; 95% CI, 0.24-0.51) 1
• Caput medusae (dilated periumbilical veins) indicates portal hypertension with portosystemic collaterals 1
• Gynecomastia and testicular atrophy reflect hormonal changes in chronic liver disease 1

Signs Specific to Etiology

• Kayser-Fleischer rings (corneal copper deposition) are pathognomonic for Wilson disease and should be sought in any patient under 40 years with unexplained liver disease 2
• Xanthomas and xanthelasmas may suggest primary biliary cholangitis 2
• Telangiectasias (particularly mucocutaneous) in the context of liver vascular malformations should prompt evaluation for hereditary hemorrhagic telangiectasia (HHT) 2

Initial Laboratory Evaluation

The essential initial laboratory panel should include bilirubin, albumin, ALT, ALP, GGT, complete blood count, INR/PT, and creatinine to assess both hepatocellular injury and synthetic function. 2, 3

Core Laboratory Tests

• ALT and AST are the primary markers of hepatocellular injury; an AST:ALT ratio >1 strongly suggests advanced fibrosis or cirrhosis 2, 3
• Alkaline phosphatase (ALP) and GGT together help identify cholestatic patterns of liver injury 2
• Bilirubin elevation indicates impaired hepatic excretory function or cholestasis 2
• Albumin is a critical marker of hepatic synthetic function; hypoalbuminemia suggests advanced disease and decreased synthetic capacity 3, 4
• INR/Prothrombin time assesses coagulation factor synthesis; elevation indicates impaired hepatic synthetic capacity and advanced disease 3, 4
• Platelet count <150,000 (thrombocytopenia) suggests portal hypertension and likely cirrhosis, with a platelet count <160 × 10³/μL having a likelihood ratio of 6.3 for cirrhosis 3, 1
• Creatinine is necessary to assess renal function, particularly important in advanced liver disease 3

Pattern Recognition for Cirrhosis

• Platelet count ≥160 × 10³/μL substantially lowers the likelihood of cirrhosis (LR 0.29; 95% CI, 0.20-0.39) 1
• Bonacini cirrhosis discriminant score >7 (combining platelet count, ALT/AST ratio, and INR) has a likelihood ratio of 9.4 for cirrhosis 1
• Lok index <0.2 (derived from platelet count, AST, ALT, and INR) has the strongest negative likelihood ratio of 0.09 for excluding cirrhosis 1
• FIB-4 index (calculated from age, AST, ALT, and platelet count) should be used to estimate fibrosis stage in all at-risk patients 3, 4

Etiologic Workup

After establishing the presence of liver disease, testing should exclude viral hepatitis, autoimmune conditions, metabolic disorders, and alcohol-related disease. 2, 3

Mandatory Screening Tests

• Hepatitis B surface antigen and hepatitis C antibody to exclude viral hepatitis 3
• Autoimmune markers: antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), and anti-mitochondrial antibody (AMA) to exclude autoimmune hepatitis and primary biliary cholangitis 3
• Iron studies (transferrin saturation and ferritin) to exclude hemochromatosis 3
• Ceruloplasmin in patients aged 3-40 years to exclude Wilson disease 2
• Alpha-1-antitrypsin level to exclude alpha-1-antitrypsin deficiency 2
• Thyroid function tests as thyroid disorders can affect liver function 2

Metabolic Risk Assessment

• Fasting glucose and/or hemoglobin A1c to evaluate for diabetes, a major risk factor for NASH and advanced fibrosis 3
• Lipid profile to assess dyslipidemia as part of metabolic syndrome 3
• Body mass index and waist circumference should be documented to assess obesity parameters 3

Critical Pitfalls to Avoid

• Normal liver enzymes do not exclude cirrhosis—advanced fibrosis may present with normal ALT and AST, making CBC and synthetic function tests (albumin, INR) essential 3, 4
• Do not rely on isolated GGT elevation as the sole marker of liver injury; it is insufficient for diagnosis 3
• In NAFLD, ALT levels are typically <5× upper limit of normal (usually between normal and 250 IU/L), with ALT typically higher than AST until advanced disease develops 3
• Medication-induced liver injury must be excluded by reviewing for hepatotoxic medications including corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, and valproic acid 3
• Liver biopsy is risky and should be avoided in patients with suspected or proven hereditary hemorrhagic telangiectasia due to high prevalence of vascular malformations 2

When to Escalate Care

• Patients with coagulation abnormality (elevated INR) and any degree of mental alteration without preexisting cirrhosis require immediate emergency room evaluation 4
• Patients with suspected acute liver failure should be referred to a transplant center immediately for expectant critical care management 4
• Patients at risk for significant fibrosis (based on clinical profile, blood tests, or imaging) should be referred to gastroenterology/hepatology for consideration of liver biopsy, appropriate follow-up, and possible clinical trial enrollment 2
• Thrombocytopenia, AST>ALT ratio, hypoalbuminemia, elevated INR, and elevated bilirubin should prompt consideration of liver biopsy or advanced imaging 3