What is the appropriate workup for a patient with cirrhosis (liver scarring) detected on a computed tomography (CT) scan?

Workup for Cirrhosis Detected on CT Scan

When cirrhosis is detected on CT scan, proceed with a comprehensive diagnostic evaluation that includes determining the etiology, assessing liver function and disease severity, screening for complications including hepatocellular carcinoma, and evaluating for portal hypertension. 1, 2

Initial Clinical and Laboratory Assessment

History and Physical Examination

• Identify risk factors for chronic liver disease: intravenous drug use, alcohol intake, metabolic syndrome components (obesity, diabetes, hypertension) 1
• Assess for signs of cirrhosis and portal hypertension: jaundice, ascites, hepatic encephalopathy, variceal bleeding, splenomegaly, spider angiomas, palmar erythema 1, 2
• Evaluate performance status: distinguish recent cancer-related symptoms from long-standing cirrhosis symptoms 1

Essential Laboratory Tests

• Determine etiology of liver disease:

  • Hepatitis B serologies (at minimum HBsAg and anti-HBc) 1
  • Hepatitis C antibody (anti-HCV) 1
  • Iron studies (ferritin, transferrin saturation) for hemochromatosis 3
  • Autoimmune markers if clinically indicated 1

• Assess liver function:

  • Prothrombin time/INR 1
  • Serum albumin 1
  • Total and direct bilirubin 1
  • Complete blood count including platelets 1

• Tumor marker: Serum alpha-fetoprotein (AFP) 1

Advanced Imaging and Fibrosis Assessment

Elastography for Confirmation and Staging

MR elastography is currently the most accurate imaging modality for diagnosis and staging of hepatic fibrosis and should be performed when available, as it compares favorably to other methods particularly in obese patients. 2, 4

• Transient elastography (FibroScan) is an alternative non-invasive option, with values >15 kPa strongly suggesting compensated advanced chronic liver disease 2
• For hepatitis C specifically, a cutoff of 12.5 kPa has 86% sensitivity and 91% specificity for cirrhosis diagnosis 2

Important caveat: Elastography results can be falsely elevated by recent meals, acute inflammation, cholestasis, and hepatic congestion. 2

Enhanced Cross-Sectional Imaging

• Multiphasic contrast-enhanced CT or MRI should be performed to better characterize liver morphology, evaluate for hepatocellular carcinoma, and assess vascular anatomy 1, 2
• MRI is superior to CT for visualizing bands of fibrosis on both noncontrast and contrast-enhanced sequences 2
• CT of chest, abdomen, and pelvis to rule out extrahepatic spread if malignancy is suspected 1

Critical limitation: CT has low sensitivity for diagnosing early cirrhosis, as morphological changes may not be apparent until very advanced stages. 2, 4 Noncontrast CT is particularly limited, demonstrating only gross structural changes in advanced disease. 1

Assessment for Portal Hypertension

Endoscopic Evaluation

• Upper endoscopy to evaluate for esophageal varices and hypertensive gastropathy 1
• This is essential as varices require prophylaxis with nonselective beta-blockers 3

Optional Advanced Assessment

• Transjugular measurement of hepatic-venous pressure gradient may be considered in select cases 1

Hepatocellular Carcinoma Surveillance

All patients with confirmed cirrhosis should undergo HCC surveillance with ultrasound every 6 months, combined with serum AFP estimation. 1, 3, 5

• Ultrasound should be performed with dedicated equipment by an operator skilled in assessing cirrhotic livers 1
• If surveillance ultrasound detects a focal lesion, proceed with multiphasic contrast-enhanced CT or MRI for characterization 1
• Biopsy should be avoided for potentially operable lesions due to 1-3% risk of tumor seeding in the needle tract 1

Liver Biopsy Considerations

Liver biopsy should be reserved for cases where non-invasive evaluation is indeterminate or when results may alter management. 2, 6

The American College of Radiology recommends avoiding biopsy when unnecessary due to its invasive nature, risk of complications, sampling errors, and limited acceptance for longitudinal monitoring. 2

Specific Populations at High Risk for HCC Surveillance

The following cirrhotic patients warrant HCC surveillance:

• Males and females with HBV cirrhosis, particularly with ongoing viral replication 1
• Males and females with hepatitis C cirrhosis 1
• Males and females with genetic hemochromatosis cirrhosis 1
• Males with alcohol-related cirrhosis who are abstinent or likely to comply with treatment 1
• Males with primary biliary cirrhosis 1

Disease Severity Scoring

Calculate Child-Pugh and Model for End-Stage Liver Disease (MELD) scores to assess prognosis and determine need for liver transplantation evaluation (indicated for MELD ≥15). 6, 5

Common Pitfalls

• Do not rely solely on CT morphology for diagnosis: Even when multiple morphologic features are assessed together, CT has low sensitivity for cirrhosis and noncirrhotic fibrosis. 2, 4
• Recognize that cirrhosis progression can be clinically silent: Most patients remain asymptomatic until decompensation occurs. 2, 3
• In obese patients: Limited ultrasound penetration makes evaluation difficult; consider MR elastography over ultrasound-based methods. 2, 4
• Avoid hepatotoxic medications in confirmed cirrhosis patients. 6