What labs should be ordered for a patient with suspected alcoholic cirrhosis?

Laboratory Evaluation for Alcoholic Cirrhosis

Order a comprehensive hepatic function panel including complete blood count, comprehensive metabolic panel with liver enzymes (AST, ALT, bilirubin, alkaline phosphatase, GGT), albumin, PT/INR, platelet count, and creatinine to assess synthetic function, portal hypertension, and prognosis. 1

Core Laboratory Panel

The essential initial workup should include:

• Complete blood count to evaluate for thrombocytopenia (platelet count <150,000), which suggests portal hypertension and likely cirrhosis 2, 1
• Comprehensive metabolic panel including AST, ALT, bilirubin, alkaline phosphatase, albumin, and creatinine 2, 1
• PT/INR to assess hepatic synthetic function—this is critical for Child-Pugh and MELD scoring 1
• GGT for detecting hepatobiliary involvement and calculating fibrosis indices 1, 3

Pattern Recognition for Cirrhosis Severity

Key laboratory patterns help identify advanced disease:

• AST/ALT ratio >2 is highly suggestive of alcoholic liver disease, with ratios >3 being even more specific 3
• AST and ALT typically do not exceed 400 IU/mL in alcoholic cirrhosis—higher values suggest drug-induced injury or ischemic hepatitis 3
• Hypoalbuminemia indicates decreased synthetic function and advanced disease 2
• Elevated INR or prolonged PT indicates impaired hepatic synthetic capacity 2
• Elevated conjugated bilirubin indicates advanced disease 1

Critical Pitfall: Normal Enzymes Don't Exclude Cirrhosis

Normal liver enzymes do not exclude significant alcoholic liver disease or cirrhosis. 2, 3 In fact, 70 out of 78 patients with documented alcoholic cirrhosis had normal ALT levels, and aminotransferase levels bore no relationship to clinical events or outcomes 4. This is why synthetic function tests (albumin, INR) and platelet count are essential even when transaminases are normal 2.

Prognostic Scoring Systems

Calculate these scores using the laboratory values obtained:

• MELD-Na score using bilirubin, INR, creatinine, and sodium to predict mortality—scores range from 6 to 40, with 3-month survival ranging from 90% to 7% respectively 1
• Child-Pugh score using albumin, bilirubin, INR, and clinical parameters 1
• FIB-4 index using age, AST, ALT, and platelet count to estimate fibrosis stage 2

Alcohol Use Monitoring

• GGT and mean corpuscular volume (MCV) are commonly elevated in chronic alcohol use and can indicate ongoing consumption 1, 3
• For detecting recent drinking in patients with established cirrhosis, GGT cut-offs of 288 U/L in men and 138 U/L in women give 90% specificity 5
• AST cut-off of 85 U/L gives 90% specificity for recent alcohol use 5

Excluding Alternative Liver Disease Etiologies

Test for coexisting conditions that may worsen prognosis:

• Hepatitis B surface antigen to exclude chronic hepatitis B 2
• Hepatitis C antibody to screen for hepatitis C infection 2
• Iron studies (transferrin saturation and ferritin) to exclude hemochromatosis 2
• Autoimmune markers (ANA, anti-smooth muscle antibody, anti-mitochondrial antibody) if etiology is unclear 2, 1

Screening for Complications

Once cirrhosis is established:

• Perform diagnostic paracentesis immediately in all patients with new-onset ascites or any hospitalized patient with cirrhosis—obtain cell count with differential, total protein, albumin, and culture to rule out spontaneous bacterial peritonitis 1
• Calculate serum-ascites albumin gradient (SAAG) to confirm portal hypertension as the cause of ascites 1
• Screen for hepatocellular carcinoma with ultrasound every 6 months, as the incidence ranges from 7-16% at 5 years to 29% at 10 years in alcoholic cirrhosis 6, 3

Monitoring Schedule

• Patients with decompensated cirrhosis require liver function tests every 1-3 months 1
• Stable compensated cirrhosis patients should have laboratory monitoring every 6 months including Child-Pugh and MELD score components 1

Additional Considerations

• Screen for extrahepatic complications including alcoholic cardiomyopathy, IgA-induced nephropathy, pancreatitis, and nutritional deficiencies 6, 3
• Assess nutritional status with careful clinical and analytical evaluation, as patients with alcoholic cirrhosis are often malnourished 6
• Refer to alcohol addiction services for all patients with AUDIT score >19 6