What tests should be ordered for a patient with a history of alcoholic cirrhosis?

Testing Strategy for Patients with Established Alcoholic Cirrhosis

For a patient with known alcoholic cirrhosis, order a comprehensive metabolic panel, complete blood count with platelets, PT/INR, liver ultrasound every 6 months for hepatocellular carcinoma screening, and upper endoscopy for variceal screening unless platelets are >150,000/μL and liver stiffness is <20 kPa. 1

Core Laboratory Tests

Liver Function and Synthetic Capacity

• Complete metabolic panel including serum albumin, total and direct bilirubin, and creatinine to assess liver synthetic function and renal status 1
• Prothrombin time/INR to evaluate coagulation status and severity of liver dysfunction 1
• AST and ALT to monitor ongoing hepatocellular injury, though these may be normal or only mildly elevated in established cirrhosis 1, 2
• Alkaline phosphatase and GGT to assess for cholestatic features, though GGT loses specificity in advanced disease 3, 2

Hematologic Assessment

• Complete blood count with platelet count to detect thrombocytopenia (marker of portal hypertension and hypersplenism) and anemia 1
• Mean corpuscular volume (MCV) which is commonly elevated in chronic alcohol use 3

Critical caveat: Normal liver enzymes do NOT exclude significant ongoing liver disease or complications in established cirrhosis. 3, 2 Up to 40% of manifest alcoholic cirrhosis can be missed by routine laboratory testing alone. 4

Severity Scoring Systems

Calculate Child-Pugh score and MELD score every 6 months for prognostic assessment and transplant evaluation timing. 5 Patients with MELD ≥15 warrant evaluation for liver transplantation. 5

Hepatocellular Carcinoma Surveillance

• Liver ultrasound every 6 months is mandatory for all cirrhotic patients, as HCC incidence in alcoholic cirrhosis ranges from 7-16% at 5 years to 29% at 10 years 1
• Alpha-fetoprotein can be added but ultrasound remains the primary screening modality 5

Portal Hypertension and Variceal Screening

Upper Endoscopy Indications

• Perform screening upper endoscopy to evaluate for esophageal varices in all newly diagnosed cirrhotic patients 1
• Exception (Baveno criteria): Endoscopy can be safely deferred if platelets >150,000/μL AND liver stiffness <20 kPa by transient elastography 1
• Repeat endoscopy timing depends on initial findings: every 2-3 years if no varices, every 1-2 years for small varices without high-risk features 5

Non-Invasive Fibrosis Monitoring

Transient Elastography (FibroScan)

• Liver stiffness measurement at 12.5 kPa cutoff has 95% sensitivity for detecting cirrhosis in alcoholic liver disease 6, 1
• This cutoff was deliberately chosen to minimize false negatives, accepting higher false positives because missing cirrhosis carries greater harm 1
• Important limitation: Repeat measurement after ≥1 week of alcohol abstinence if AST or GGT >2× upper limit of normal, as active inflammation falsely elevates readings 6

Alternative Non-Invasive Tests

If transient elastography unavailable, use: 6

• Enhanced Liver Fibrosis (ELF™) test with cutoff <9.8 to rule out advanced fibrosis
• FibroMeter™ <0.45 or FibroTest® <0.48
• FIB-4 score <1.3 (calculated from age, AST, ALT, platelet count)

Excluding Coexisting Liver Disease

Test for viral hepatitis (HBV surface antigen, HCV antibody with reflex RNA) as up to 20% of patients with alcohol use disorder have coexisting liver disease etiologies. 3, 2 This is particularly important because concurrent etiologies worsen prognosis and may require specific treatment.

Assessing for Decompensation

When Ascites is Present or Suspected

• Diagnostic paracentesis with cell count, differential, albumin, total protein, and culture (inoculate blood culture bottles at bedside) 5
• Calculate serum-ascites albumin gradient (SAAG) to confirm portal hypertension as etiology 5

When Hepatic Encephalopathy is Suspected

• Ammonia level can support diagnosis but is not required; clinical assessment is primary 5
• Rule out precipitating factors: infection, gastrointestinal bleeding, electrolyte abnormalities, medications 5

Alcohol Use Monitoring

Screening Tools

• AUDIT questionnaire (positive if score ≥8 for men up to age 60, or ≥4 for women/elderly) to objectively assess ongoing alcohol use disorder 3, 2
• Consider referral to alcohol services if AUDIT score >19 indicating alcohol dependency 6

Direct Biomarkers (When History Unreliable)

• Ethyl glucuronide (EtG) in urine detects alcohol use for up to 3-4 days 3, 2
• Hair EtG detects chronic excessive consumption with cutoff >30 pg/mg indicating chronic excessive use 3, 2

When to Consider Liver Biopsy

Liver biopsy is NOT routinely needed in established cirrhosis but should be considered in specific scenarios: 1, 2

• Suspected acute alcoholic hepatitis requiring corticosteroid treatment (for definitive diagnosis and prognosis)
• Discordant or inconclusive non-invasive test results
• Suspected coexisting chronic liver disease (e.g., autoimmune hepatitis, hemochromatosis)
• Atypical presentation with confounding factors

Use transjugular approach in patients with coagulopathy, thrombocytopenia, or ascites. 1, 2

Extrahepatic Complications Assessment

Screen for alcohol-related extrahepatic complications: 1

• Cardiac evaluation for alcoholic cardiomyopathy if symptomatic
• Renal function monitoring for IgA nephropathy
• Neurologic assessment for peripheral neuropathy and cognitive impairment
• Pancreatic imaging if abdominal pain suggests chronic pancreatitis
• Nutritional assessment for thiamine, folate, and vitamin deficiencies

Monitoring Frequency

Every 6 months for stable compensated cirrhosis: 5

• Complete metabolic panel, CBC with platelets, PT/INR
• Child-Pugh and MELD score calculation
• Liver ultrasound for HCC screening

More frequent monitoring (every 3 months or as clinically indicated) for decompensated cirrhosis or active complications. 5