What is the recommended workup for a patient with suspected cirrhosis?

Workup for Suspected Cirrhosis

Begin with a comprehensive hepatic function panel, complete blood count, renal function tests, and abdominal ultrasound, followed immediately by transient elastography and etiologic testing to confirm diagnosis and assess severity. 1, 2

Initial Laboratory Evaluation

Obtain the following tests immediately when cirrhosis is suspected:

• Hepatic function panel: Bilirubin (total and conjugated), AST, ALT, alkaline phosphatase, GGT, albumin, and PT/INR 1
• Complete blood count with differential: Thrombocytopenia (platelet count <150,000/µL) suggests portal hypertension and advanced disease 1
• Renal function tests: Creatinine and BUN are essential for MELD score calculation and detecting hepatorenal syndrome 1
• Serum electrolytes: Sodium is critical for MELD-Na scoring and detecting hyponatremia, an independent predictor of mortality 3

Key laboratory patterns to recognize:

• AST/ALT ratio >1 typically indicates cirrhosis rather than acute hepatitis 1
• Elevated conjugated bilirubin indicates advanced disease or biliary obstruction 1
• Prolonged PT/INR reflects impaired hepatic synthetic function and is critical for Child-Pugh and MELD scoring 1
• Low albumin (<3.5 g/dL) indicates impaired synthetic function and poor prognosis 1

Etiologic Workup

Perform these tests to identify the underlying cause:

• Viral hepatitis panel: HBsAg, hepatitis B core antibody (total and IgM), hepatitis B surface antibody, and HCV antibody with reflex viral load if positive 1, 4
• Iron studies: Ferritin and transferrin saturation to screen for hemochromatosis 1, 5
• Autoimmune markers: ANA, anti-smooth muscle antibody, anti-mitochondrial antibody if etiology unclear 1
• Alpha-1 antitrypsin level: Particularly in younger patients or those with emphysema 1
• Ceruloplasmin: For Wilson disease screening, especially in patients under age 40 1

Initial Imaging Studies

Abdominal ultrasound is mandatory as the first-line imaging test:

• Assess liver morphology for nodular surface (86% sensitive on undersurface, 53% on superior surface), right lobe atrophy, caudate lobe hypertrophy 1, 2
• Detect ascites and measure spleen size 2
• Screen for hepatocellular carcinoma 2
• Evaluate portal vein diameter (>13 mm suggests portal hypertension) and identify collateral vessels 2
• Rule out biliary obstruction with 71-97% specificity 1

Ultrasound has 65-95% sensitivity and 98% positive predictive value for detecting cirrhosis. 1

Non-Invasive Fibrosis Assessment

Transient elastography (FibroScan) should be performed next:

• Liver stiffness <6.4 kPa: Rules out advanced fibrosis 1
• Liver stiffness ≥15 kPa: Confirms compensated advanced chronic liver disease/cirrhosis 1, 2
• Liver stiffness 12.5 kPa: Recommended cutoff by AGA for detecting cirrhosis in alcoholic liver disease, prioritizing sensitivity over specificity to avoid missing cases 3

Calculate non-invasive fibrosis scores using initial laboratory values:

• APRI score: (AST/upper limit normal) × 100 / platelet count 1
• FIB-4 score: (Age × AST) / (platelet count × √ALT) 1

Severity Assessment and Prognostication

Calculate prognostic scores immediately:

• Child-Pugh score: Uses bilirubin, albumin, INR, ascites grade, and encephalopathy grade; Class C (score 10-15) carries >33% one-year mortality 2
• MELD score: Uses bilirubin, INR, and creatinine; scores range 6-40 with 3-month survival from 90% to 7% respectively 2
• MELD-Na score: Incorporates sodium for improved prognostic accuracy 3

Screening for Complications

If ascites is present or develops:

• Perform diagnostic paracentesis immediately in all patients with new-onset grade 2 or 3 ascites or any hospitalized patient with cirrhosis 3, 2
• Ascitic fluid analysis: Cell count with differential (neutrophils >250/µL diagnoses spontaneous bacterial peritonitis), total protein, albumin, and bedside inoculation of 10 mL into blood culture bottles 3
• Calculate serum-ascites albumin gradient (SAAG): SAAG ≥1.1 g/dL confirms portal hypertension as the cause 3

Variceal screening:

• Upper endoscopy is recommended for all patients with newly diagnosed cirrhosis unless low-risk criteria are met (platelets >150,000/µL AND liver stiffness <20 kPa) 1, 4

Hepatocellular carcinoma screening:

• Abdominal ultrasound with serum AFP every 6 months for all patients with established cirrhosis 1, 2

Advanced Imaging When Indicated

• MRI with MRCP: Consider if ultrasound is negative but clinical suspicion remains high, particularly for cholestatic diseases (primary sclerosing cholangitis, primary biliary cholangitis) 1
• MR elastography: Most accurate imaging modality for diagnosing and staging hepatic fibrosis when available 2
• Multiphasic CT or MRI: When hepatocellular carcinoma is suspected based on screening ultrasound 1

Monitoring Schedule for Established Cirrhosis

Compensated cirrhosis:

• Liver function tests, CBC, and prognostic scores every 6 months 1, 6
• Ultrasound with AFP for HCC screening every 6 months 1, 2
• Upper endoscopy for variceal surveillance per initial findings 1

Decompensated cirrhosis:

• Liver function tests every 1-3 months 1
• More frequent monitoring based on specific complications 1

Immediate Referral Indications

Refer to gastroenterology/hepatology urgently when:

• Any decompensation event occurs (ascites, variceal bleeding, hepatic encephalopathy) 2
• MELD score ≥15 2, 6
• Refractory ascites develops 2
• Hepatocellular carcinoma is detected 2
• Child-Pugh Class C cirrhosis 2

Critical Clinical Pitfalls to Avoid

Do not delay diagnosis based on normal or mildly elevated transaminases: Patients with established cirrhosis frequently have near-normal ALT/AST levels; persistent abnormalities over 3-6 months warrant full evaluation even if only mildly elevated 1, 2

Do not rely solely on conventional imaging for early cirrhosis: Morphological changes on CT, MRI, or ultrasound may not appear until very advanced stages 2

Never delay diagnostic paracentesis in hospitalized patients with ascites: SBP can present without typical symptoms, and mortality increases 10% for every hour's delay in initiating antibiotics in septic patients 3

Avoid NSAIDs in all cirrhotic patients: They reduce urinary sodium excretion, worsen ascites, and can precipitate acute kidney injury 2

Do not use age and sex-normative values for liver enzymes: Avoid high thresholds (>1.5-2× upper limit of normal) that delay diagnosis 1