What laboratory tests and management strategies are recommended for a patient with suspected cirrhosis?

Laboratory Testing for Suspected Cirrhosis

For patients with suspected cirrhosis, obtain a comprehensive hepatic function panel including AST, ALT, alkaline phosphatase, total and conjugated bilirubin, albumin, PT/INR, complete blood count with platelets, and renal function tests (creatinine, BUN, sodium) as the initial diagnostic workup. 1

Initial Diagnostic Laboratory Panel

The core laboratory assessment should include:

• AST and ALT: These aminotransferases are typically elevated in active liver injury, with an AST/ALT ratio often >1 in established cirrhosis 1, 2
• Alkaline phosphatase (ALP): May be elevated, particularly in cholestatic liver disease, though isolated ALP elevation is common in malignancy and should not be used alone for diagnosis 3, 1
• GGT: Useful for detecting hepatobiliary involvement and calculating fibrosis indices 1, 4
• Total and conjugated bilirubin: Elevated conjugated bilirubin indicates advanced disease or biliary obstruction 1, 2
• Albumin: Decreased levels reflect impaired synthetic function and are essential for Child-Pugh scoring 1, 4
• PT/INR: Prolonged values indicate impaired hepatic synthetic function and are critical for both Child-Pugh and MELD scoring 1, 2
• Complete blood count with platelets: Thrombocytopenia (low platelet count) suggests portal hypertension and serves as a surrogate marker for advanced disease 1, 2
• Creatinine, BUN, and sodium: Essential for MELD-Na score calculation and detecting hepatorenal syndrome 1, 4

Etiologic Workup

Once cirrhosis is suspected, determine the underlying cause with targeted testing:

• Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis C antibody: Screen all patients, with viral load confirmation if positive to guide antiviral therapy 1, 2
• Ferritin and transferrin saturation: Screen for hemochromatosis 1, 2
• Autoimmune markers (ANA, ASMA, immunoglobulins): Consider if etiology is unclear 1, 2
• Alpha-1 antitrypsin level: Screen for alpha-1 antitrypsin deficiency 1, 2
• Ceruloplasmin: Consider for Wilson disease, particularly in younger patients 1

Non-Invasive Fibrosis Assessment

Calculate fibrosis indices using readily available laboratory values:

• FIB-4 index: Uses age, AST, ALT, and platelets to track fibrosis progression 1, 4
• APRI (AST to platelet ratio index): Another validated fibrosis marker 1, 4
• Transient elastography: Liver stiffness <6.4 kPa rules out advanced fibrosis; ≥15 kPa typically confirms cirrhosis 1

For alcoholic liver disease specifically, use a liver stiffness cutoff of 12.5 kPa to detect cirrhosis, prioritizing sensitivity to avoid missing cases 1

Prognostic Scoring Systems

Calculate these scores to assess disease severity and prognosis:

• MELD-Na score: Incorporates bilirubin, INR, creatinine, and sodium for improved prognostic accuracy, with scores ranging from 6 to 40 predicting 3-month survival from 90% to 7% respectively 1, 4
• Child-Pugh score: Assesses albumin, bilirubin, INR, plus clinical findings of ascites and encephalopathy 1, 4

Critical Pitfalls to Avoid

Do not wait for liver enzymes to exceed 1.5-2× upper limit of normal before pursuing evaluation. Use age and sex-normative values, as delayed diagnosis commonly occurs when clinicians wait for higher thresholds 1

• Persistent abnormalities over 3-6 months warrant further evaluation even if only mildly elevated 1
• Recognize that transient elevations can occur; perform screening during clinical stability 1
• Routine ammonia level testing in patients with altered mental status is not recommended, as ammonia levels are variable and may be elevated in non-hepatic encephalopathy conditions 3
• Serum aminotransferase levels may be normal in up to half of cirrhotic patients, so normal ALT/AST does not exclude cirrhosis 3

Screening for Complications

When ascites is present or develops:

• Perform diagnostic paracentesis immediately without delay to rule out spontaneous bacterial peritonitis in any hospitalized patient with cirrhosis or new-onset ascites 1, 3
• Obtain ascitic fluid cell count with differential, total protein, albumin, and inoculate 10 mL into blood culture bottles at bedside 1
• Calculate serum-ascites albumin gradient (SAAG) to confirm portal hypertension as the cause 1

Ongoing Monitoring Schedule

For patients with established compensated cirrhosis:

• Obtain comprehensive metabolic panel, complete blood count with platelets, and PT/INR every 6 months 1, 5
• Liver ultrasound every 6 months for hepatocellular carcinoma surveillance, as HCC incidence ranges from 7-16% at 5 years 1, 5
• Recalculate MELD-Na, Child-Pugh, and FIB-4 scores every 6 months 1, 5

For decompensated cirrhosis or active complications, increase laboratory monitoring frequency to every 1-3 months 1, 5

Upper Endoscopy Screening

Perform upper endoscopy for all patients with newly diagnosed cirrhosis unless both criteria are met: platelets >150,000/μL AND liver stiffness <20 kPa by transient elastography (Baveno criteria). 1, 5 This screens for esophageal varices requiring prophylaxis 3