Does This Patient With Liver Disease Have Cirrhosis?

The Rational Clinical Examination

CLINICIAN'S CORNER

JAMA. 2012;307(8):832-842. doi: 10.1001/jama.2012.186

Jacob A. Udell, MD, MPH, FRCPC; Charlie S. Wang, MD, MSc, FRCPC; Jill Tinmouth, MD, PhD, FRCPC; J. Mark FitzGerald, MB, FRCPC; Najib T. Ayas, MD, MPH, FRCPC; David L. Simel, MD, MHS; Michael Schulzer, MD, PhD; Edwin Mak, BASc; Eric M. Yoshida, MD, MHSc, FRCPC

[+] Author Affiliations

Abstract

Context Among adult patients with liver disease, the ability to identify those most likely to have cirrhosis noninvasively is challenging.

Objective To identify simple clinical indicators that can exclude or detect cirrhosis in adults with known or suspected liver disease.

Data Sources We searched MEDLINE and EMBASE (1966 to December 2011) and reference lists from retrieved articles, previous reviews, and physical examination textbooks.

Study Selection We retained 86 studies of adequate quality that evaluated the accuracy of clinical findings for identifying histologically proven cirrhosis.

Data Extraction Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality. Random-effects meta-analyses were used to calculate summary LRs across studies.

Results Among the 86 studies, 19 533 patients were included in this meta-analysis, among whom 4725 had biopsy-proven cirrhosis (prevalence rate, 24%; 95% CI, 20%-28%). Many physical examination and simple laboratory tests increase the likelihood of cirrhosis, though the presence of ascites (LR, 7.2; 95% CI, 2.9-12), a platelet count <160 × 10³/μL (LR, 6.3; 95% CI, 4.3-8.3), spider nevi (LR, 4.3; 95% CI 2.4-6.2), or a combination of simple laboratory tests with the Bonacini cirrhosis discriminant score >7 (LR, 9.4; 95% CI, 2.6-37) are the most frequently studied, reliable, and informative results. For lowering the likelihood of cirrhosis, the most useful findings are a Lok index <0.2 (a score created from the platelet count, serum aspartate aminotransferase and alanine aminotransferase, and prothrombin international normalized ratio; LR, 0.09; 95% CI, 0.03-0.31); a platelet count ≥160 × 10³/μL (LR, 0.29; 95% CI, 0.20-0.39); or the absence of hepatomegaly (LR, 0.37; 95% CI, 0.24-0.51). The overall impression of the clinician was not as informative as the individual findings or laboratory combinations.

Conclusions For identifying cirrhosis, the presence of a variety of clinical findings or abnormalities in a combination of simple laboratory tests that reflect the underlying pathophysiology increase its likelihood. To exclude cirrhosis, combinations of normal laboratory findings are most useful

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Related article

JAMA Patient Page

Cirrhosis

Ann R. Punnoose, MD, Writer; Cassio Lynm, MA, Illustrator; Robert M. Golub, MD, Editor

JAMA. 2012;307(8):874.doi:10.1001/jama.2012.82

Cirrhosis is the end stage of any condition in which the liver progressively becomes scarred. It is diagnosed based on physical findings as well as a microscopic examination of liver tissue from a biopsy (tissue sample) or evidence from other diagnostic tests such as ultrasound. Under the microscope, cirrhosis appears as widespread bands of fibrous (made up of fibers) tissue that divide the liver into nodules (small knots or collections of tissue). Eventually, cirrhosis interferes with the function of the liver and can lead to liver failure or liver cancer. The February 22/29, 2012, issue of JAMA includes an article on diagnosing cirrhosis.

COMMON RISK FACTORS

• Hepatitis B or C infection

• Autoimmune liver diseases, which include autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis

• Nonalcoholic fatty liver disease, often found in obese individuals who do not drink alcohol. Although it can have a benign course, it can sometimes progress to cirrhosis.

• Hereditary metabolic liver diseases, such as hemochromatosis (iron overload), Wilson disease (copper overload), and α₁-antitrypsin deficiency (inability to make a type of protein)

• Long-term exposure to excess amounts of alcohol can lead to inflammation in the liver, which eventually causes cirrhosis.

PHYSICAL FINDINGS

• Because the liver does not appropriately process bile (a fluid that helps absorb digested fats) and bilirubin (a waste product), jaundice or yellowing of the skin may occur.

• Palmar erythema (redness of the palms), spider angiomas (blood vessels that spread out in a spider shape), gynecomastia (breast enlargement in men), decreased body hair, and shrinking of the testicles may occur.

• Patients can experience spontaneous bleeding because the liver is unable to make factors in the blood that form normal clots.

• As cirrhosis progresses, it becomes increasingly difficult for blood to travel through the vessels in the liver. This causes increased pressure (portal hypertension) in the portal vein (the major vein in the liver). This results in the formation of esophageal varices (enlarged veins in the esophagus) that can bleed easily.

• The liver is responsible for making several proteins, like albumin. Portal hypertension and low albumin levels cause ascites (accumulation of fluid in the abdominal space) and edema (water retention leading to swelling in dependent areas).

• As the liver fails, it becomes unable to remove toxins from the body. This buildup can affect a person's level of awareness, called hepatic encephalopathy.

TREATMENT

• If possible, treat the illness that led to cirrhosis to prevent progression or worsening of cirrhosis before liver failure or cancer develops.

• Control complications that cirrhosis causes by supplementing nutrition, transfusing clotting factors to prevent bleeding, and using medications to reduce ascites, edema, and the buildup of toxins.

• Avoid alcohol and any medications that could affect the liver.

• When cirrhosis progresses and the complications can no longer be controlled, physicians and their patients may discuss liver transplantation.

FOR MORE INFORMATION

• Mayo Clinic
  www.mayoclinic.com/health/cirrhosis/DS00373

• National Digestive Diseases Information Clearinghouse
  digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/index.aspx

INFORM YOURSELF

To find this and previous JAMA Patient Pages, go to the Patient Page link on JAMA's website at www.jama.com. Many are available in English and Spanish. A Patient Page on liver transplantation was published in the January 18, 2012, issue.

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