Last reviewed: May 2019
Last updated: August  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • older age
  • hepatomegaly

Other diagnostic factors

  • abdominal distention
  • oesophageal or gastric variceal bleeding
  • right upper quadrant pain
  • early satiety
  • weight loss
  • leg oedema
  • hepatic encephalopathy
  • cachexia
  • jaundice
  • splenomegaly
  • asterixis
  • spider naevi
  • palmar erythema
  • periumbilical collateral veins
  • fetor hepaticus
  • diarrhoea
  • paraneoplastic syndrome
  • bony pain
  • severe abdominal pain
  • obstructive jaundice
  • enlarged haemorrhoidal veins
  • vascular bruit

Risk factors

  • cirrhosis
  • chronic hepatitis B (HBV) infection
  • chronic hepatitis C (HCV) cirrhosis
  • chronic heavy alcohol use
  • diabetes
  • obesity
  • family history of liver cancer
  • aflatoxin
  • Thorotrast radioactive contrast
  • haemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cirrhosis (PBC)
  • primary sclerosing cholangitis
  • androgenic steroids
  • oral contraceptives
  • male sex

Diagnostic investigations

1st investigations to order

  • full blood count
  • basic metabolic panel
  • liver function tests
  • prothrombin time/international normalised ratio
  • viral hepatitis panel
  • alpha fetoprotein (AFP)
  • ultrasound of liver
Full details

Investigations to consider

  • contrast computed tomography (CT) scan of abdomen
  • contrast magnetic resonance imaging (MRI) of abdomen
  • liver biopsy
  • computed tomography scan of chest
  • bone scan
Full details

Treatment algorithm


Authors VIEW ALL

Consultant, Gastroenterology & Hepatology

Assistant Professor, Yong Loo Lin School of Medicine

National University of Singapore



PST has received a speaker honorarium from GE Healthcare, Bayer, and Sirtex. PST has received travel and accommodation arrangements for medical conferences from Bristol-Myers Squibb, Gilead, Sirtex, Bayer, and Novartis.

Dr Poh Seng Tan would like to gratefully acknowledge Dr Badar Muneer and Dr Smruti R. Mohanty, previous contributors to this monograph. BM declares that he has no competing interests. SRM serves as a speaker for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewers VIEW ALL


Dartmouth-Hitchcock Nashua




SN declares that he has no competing interests.

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch




NS declares that he has no competing interests.

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