Identifying the presence of cirrhosis is essential in any patient with chronic liver disease. Making the diagnosis of cirrhosis will affect management and follow-up.

Key concepts

• Cirrhosis is the end stage of any chronic liver disease, such as hepatitis B, hepatitis C, alcohol-related liver disease, or metabolic dysfunction-associated steatotic liver disease
• Clinical stages of cirrhosis: compensated and decompensated
  • Patients with compensated cirrhosis may have gastroesophageal varices, but they never developed complications such as ascites, hepatic encephalopathy or variceal hemorrhage. The diagnosis of cirrhosis can usually be established without a liver biopsy, using clinical findings, imaging, lab tests and/or elastography
  • Decompensated cirrhosis is characterized by the presence or development of ascites, variceal hemorrhage, or hepatic encephalopathy; a liver biopsy is rarely needed to confirm cirrhosis

Key recommendations

• Cirrhosis should be investigated in patients with chronic (>6 months in duration) abnormalities in liver enzymes and/or in patients in whom risk factors for cirrhosis are present: alcohol use disorder, hepatitis C, hepatitis B, obesity, and metabolic syndrome (even in the absence of liver enzyme abnormalities)
• The following can help support the diagnosis of cirrhosis:
  • Careful physical exam
  • Appropriate laboratory tests
  • Appropriate imaging tests
  • Liver stiffness measurements
• However, physical exam, laboratory tests, and radiology tests (clinical findings) all may yield entirely normal results in a patient with compensated cirrhosis
• Liver biopsy (an invasive method) is required to establish (or exclude) the diagnosis of cirrhosis when there is high suspicion but absence of non-invasive findings

The diagnosis of decompensated cirrhosis is usually easy and straightforward. However, for compensated cirrhosis, a combination of clinical judgement, laboratory tests (e.g. FIB-4, imaging finding) should be used. Finally, elastography is the best non-invasive assessment of fibrosis.

Physical exam findings suggestive of decompensated cirrhosis (difficult to diagnose compensated cirrhosis with physical exam):

Exam Finding	Example
Bitemporal muscle wasting	Loss of muscle mass in the temporal area
Spider angioma	Blood vessel formation on the skin of the chest, back and face in the shape of a spider that fill from the center outward when blanched
Palmar erythema	Redness on the palms of the hands
Ascites	Fluid accumulation in the abdomen
Abdominal collaterals (caput medusae)	Large venous collateral drainage on the surface of the abdomen
Palpation/percussion	Palpable left lobe of the liver (in the epigastrium) Splenomegaly Small liver span (right lobe: normal is ~9 cm) Shifting dullness (ascites)

Laboratory findings suggestive of cirrhosis:

• Platelet count < 150,000 (if no other explanation)
• Albumin < 3.5 mg/dL (if no albuminuria, malnutrition)
• AST > ALT
• INR > 1.2
• Bilirubin > 1.5 mg/dL (very non-specific, rule out Gilbert syndrome)
• FIB-4 or APRI scores calculated using age, AST, ALT, and/or platelet count (high negative predictive value)
• Specialized tests such as Enhanced Liver Fibrosis (not widely available)

Imaging findings (abdominal ultrasound, CT, or MRI) suggestive of cirrhosis:

• Nodular surface of the liver (subjective)
• Splenomegaly
• Collaterals or varices
• Enlarged caudate lobe/left lobe of the liver
• Shrunken right lobe of the liver
• Ascites

Elastographic findings suggestive of cirrhosis:

• Transient elastography (Fibroscan^®) is a point-of-care method to measure liver stiffness (LS)
  • Most reliable non-invasive test for diagnosis of suspected cirrhosis
  • Most useful for excluding cirrhosis
  • LS can be falsely elevated e.g., non-fasting, aminotransferases >150 IU/mL, fluid accumulation from cardiac or renal dysfunction, and pulmonary hypertension.
• Other methods to measure liver stiffness include acoustic radiation force impulse (ARFI) and magnetic resonance elastography (MRE), but they are not point-of-care and have different cutoffs
• Combination of LS measurement and platelet count can have both diagnostic and prognostic values