Last reviewed: 24 Aug 2021
Last updated: 24 Aug 2021

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • abdominal pain
  • hepatomegaly
  • haematemesis and melaena
  • venous collaterals
  • splenomegaly
  • hepatic mass
  • jaundice
  • palmar erythema
  • cutaneous telangiectasia
  • asterixis

Other diagnostic factors

  • ascites
  • weight loss
  • weight gain
  • malnutrition and wasting
  • anorexia
  • fatigue
  • confusion
  • pruritus
  • fever
  • nausea and vomiting
  • finger clubbing
  • Dupuytren's contracture
  • leg swelling
  • parotid gland enlargement
  • gynaecomastia
  • hypogonadism
  • dementia
  • peripheral neuropathy

Risk factors

  • prolonged and heavy alcohol consumption
  • hepatitis C
  • female sex
  • cigarette smoking
  • obesity
  • age >65 years
  • Hispanic ethnicity
  • genetic predisposition

Diagnostic investigations

1st investigations to order

  • serum aspartate aminotransferase (AST), alanine aminotransferase (ALT)
  • serum AST/ALT ratio
  • serum alkaline phosphatase
  • serum bilirubin
  • serum albumin, protein
  • serum gamma glutamyl transferase (gamma-GT)
  • FBC
  • serum electrolytes, magnesium, phosphorus
  • serum urea and creatinine
  • serum prothrombin time (PT), INR
  • hepatic ultrasound

Investigations to consider

  • viral hepatitis serology
  • serum iron, ferritin, transferrin
  • urine copper (24-hour collection)
  • serum ceruloplasmin
  • serum anti-mitochondrial antibody (AMA)
  • serum anti-nuclear antibody (ANA) and anti-smooth muscle antibody (ASMA)
  • serum alpha-1 antitrypsin level
  • serum ammonia
  • serum folate
  • non-invasive tests of liver elasticity
  • CT abdomen, MRI abdomen
  • liver biopsy

Emerging tests

  • serum carbohydrate-deficient transferrin test
  • serum mitochondrial AST

Treatment algorithm

Contributors

Authors

Craig McClain, MD
Craig McClain

Professor

Chief of Research Affairs

Associate Vice President for Health Affairs/Research

Division of Gastroenterology, Hepatology and Nutrition

Department of Medicine

University of Louisville School of Medicine

Louisville

KY

Disclosures

CM acts as a consultant for Nestlé, Durect, Allergan, Intercept and DISCUS. He works for the Veterans Administration on a part time basis, has received grants from the NIH and VAMC, and is working on the update of the AGC nutritional guideline..

Luis Marsano, MD
Luis Marsano

Professor and Director of Hepatology

Division of Gastroenterology, Hepatology and Nutrition

Department of Medicine

University of Louisville School of Medicine

Louisville

KY

Disclosures

LM is on the speaker bureau for Salix (maker of Rifaximin - Xifaxan); Rifaximin is part of the therapy (supported by practice guidelines) of hepatic encephalopathy. He is also on the speaker bureau of Grifols (one of the makers of albumin for intravenous infusion); albumin is used as part of the treatment of spontaneous bacterial peritonitis (supported by practice guidelines).

Acknowledgements

Dr Craig McClain and Dr Luis Marsano would like to gratefully acknowledge Dr Mihir Patel, a previous contributor to this topic.

Disclosures

MP declares that he has no competing interests.

Peer reviewers

Lorenzo Leggio, MD, MSc

Postdoctoral Research Associate

Center for Alcohol and Addiction Studies

Brown University

Providence

RI

Disclosures

LL declares that he has no competing interests.

Nancy Reau, MD

Assistant Professor of Medicine

University of Chicago

Center for Liver Disease

Chicago

IL

Disclosures

NR declares that she has no competing interests.

Nick Sheron, MD, FRCP

Head of Clinical Hepatology and Senior Lecturer

Division of Infection, Inflammation and Immunity

University of Southampton Medical School

Southampton General Hospital NHS Trust

Southampton

UK

Disclosures

NS has received research grants from the Medical Research Council (MRC), Wellcome Trust, British Liver Trust, Alcohol Education Research Council, and various other funding bodies. He has undertaken paid consultancy work and received travelling expenses from pharmaceutical companies developing drugs for the treatment of inflammatory bowel disease and liver disease. He has been paid for medico-legal work in the areas of hepatitis C and alcohol-related liver disease. The following memberships and advisory work are unpaid apart from travelling expenses: EU Alcohol Forum, EU Alcohol Marketing Taskforce, Royal College of Physicians Alcohol Committee, Alcohol Health Alliance UK. NS has undertaken advisory and media work for the UK Department of Health, Home Office, Department of Transport, Cross Cabinet Strategy Committee, National Institute for Health and Care Excellence, Southampton City Council, UK Police, and British Liver Trust, and various other NGOs, local government, and other bodies. NS is an unpaid trustee of the Drinkaware Trust, an independent body set up by the UK Government to use industry resources to reduce alcohol-related harm. The Trust is funded entirely by the alcohol industry, with a board of trustees comprising 5 industry members, 5 members with alcohol-related health expertise, and 3 lay members.

Alastair MacGilchrist, MD, FRCP

Consultant Hepatologist

Royal Infirmary of Edinburgh

Edinburgh

UK

Disclosures

AM declares that he has no competing interests.

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