List routine lab studies.
Liver chemistries
Transaminases: ↑ ALT and AST
ALT > AST: present in most liver diseases (e.g., NAFLD, viral hepatitis)
AST > ALT: indicative of alcoholic liver disease and/or cirrhosis of any etiology
Massive AST and/or ALT elevation (> 15 times ULN): Consider differential diagnoses (e.g., acetaminophen toxicity, acute viral hepatitis, autoimmune hepatitis).
↑ Bilirubin (may be normal initially)
↑ ALP
↑ Gamma‑glutamyl transferase (GGT)
Coagulation studies: ↑ prothrombin time (↑ INR) because of decreased production of coagulation factors
CBC
Thrombocytopenia: due to decreased thrombopoietin production by the liver and/or splenomegaly [13]
Anemia: multiple potential causes, e.g., chronic blood loss, splenic sequestration, vitamin B12 or folic acid deficiency
Leukopenia
CMP
↓ Albumin
↓ Total protein
Hyponatremia
Liver chemistries may be normal in early compensated cirrhosis. [11]
Some CBC abnormalities are due to the combination of increased hepatic and splenic sequestration of thrombocytes (portal hypertension leads to splenomegaly with hypersplenism) and decreased production of hematopoietic factors by the liver.
Hepatocyte injury: ↑ AST, ALT, ALP, GGT. Synthetic dysfunction: ↑ bilirubin and PT/INR; ↓ albumin and platelets
List additional lab studies.
Viral hepatitis: especially in patients with risk factors
Hepatitis B and hepatitis C: HBsAg, IgM anti-HBc, anti-HCV
Hepatitis A and hepatitis E: IgM HAV, IgM HEV
NASH: fasting lipid levels and HbA1c
Hemochromatosis: serum iron, ferritin, transferrin saturation
Autoimmune hepatitis: total IgG or serum electrophoresis (showing hypergammaglobulinemia), ANA, ASMA, anti-LKM-1 antibody, anti-soluble liver antigen antibody
Alpha-1 antitrypsin deficiency: alpha-1 antitrypsin level and phenotype
Wilson disease: serum ceruloplasmin, serum total and free copper, urinary copper
Primary biliary cholangitis: antimitochondrial antibodies (AMA or AMA-M2), ALP, bilirubin
Primary sclerosing cholangitis: cholestasis parameters (GGT, ALP, and bilirubin), pANCA, IgG
Other tests [17][18]
Ammonia (not routinely indicated) [18]
Plasma cholinesterase
Serum protein electrophoresis
Describe the abdominal ultrasound with Doppler.
Abdominal ultrasound with Doppler Indications
Suspected cirrhosis: best initial test
Established cirrhosis: for HCC screening and detecting complications
Findings
Liver form and structure
Nodular liver surface
Atrophy of the right lobe
Loss of structural homogeneity (hyperechoic or variable increase in echogenicity) with fibrous septa
Liver size
Initially enlarged
Atrophies and shrinks with disease progression
Hypertrophy of the caudate lobe and left lobe
Atrophy of segment IV
Other possible findings
Changes in liver vasculature
Complications of portal hypertension: ascites, splenomegaly, portal vein thrombosis (PVT), increased portosystemic collateral flow
Describe the indication and findings of CT abdomen.
Indication: patients in whom adequate assessment with ultrasound is not possible (e.g., because of obesity)
Findings: similar to those on ultrasound
Relative hypertrophy of the left lobe and caudate lobe
Regenerative nodules
Irregular liver surface
Indirect findings: ascites, splenomegaly, portosystemic collaterals
Describe the indication for liver biopsy.
In cases of diagnostic uncertainty (gold standard)
Grading and staging of inflammation and fibrosis
Monitoring treatment response (e.g., in autoimmune hepatitis)
Evaluation of focal lesions
Describe the screeninf for complications.
Screening for esophageal varices: EGD at time of diagnosis and every 1–3 years depending on the presence and size of the varices on initial screening
HCC screening: abdominal ultrasound every 6 months
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