Last reviewed: 5 Nov 2021
Last updated: 24 May 2019



History and exam

Key diagnostic factors

  • presence of risk factors
  • absence of significant alcohol use
  • fatigue and malaise
  • hepatosplenomegaly
  • truncal obesity

Other diagnostic factors

  • right upper quadrant abdominal discomfort
  • pruritus
  • jaundice
  • spider angioma
  • palmar erythema
  • nail changes
  • Dupuytren's contracture
  • bruising
  • petechiae
  • excoriations
  • gynaecomastia
  • parotid gland enlargement
  • testicular atrophy
  • alopecia
  • caput medusae
  • Cruveilhier-Baumgarten murmur
  • peripheral oedema
  • ascites
  • low blood pressure
  • hepatic encephalopathy
  • asterixis
  • fetor hepaticus
  • haematemesis
  • melaena

Risk factors

  • obesity
  • insulin resistance or diabetes
  • dyslipidaemia
  • hypertension
  • metabolic syndrome
  • rapid weight loss
  • hepatotoxic medications
  • total parenteral nutrition (TPN)
  • diseases associated with fatty liver deposition

Diagnostic investigations

1st investigations to order

  • serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
  • total bilirubin
  • alkaline phosphatase
  • gamma glutamyl transferase
  • FBC
  • metabolic panel
  • lipid panel
  • prothrombin time and INR
  • serum albumin
  • antinuclear antibody (ANA) and anti-smooth muscle antibody
  • iron studies

Investigations to consider

  • fasting insulin
  • homeostatic model assessment (HOMA) calculation
  • alpha fetoprotein
  • serum ammonia
  • model for end-stage liver disease (MELD) score calculation
  • serum albumin to ascitic fluid albumin gradient
  • liver ultrasound
  • abdominal CT scan
  • abdominal MRI
  • oesophogastroduodenoscopy
  • EEG
  • portal venous pressure measurements
  • liver biopsy

Emerging tests

  • elastography
  • cytokeratin-18 fragments

Treatment algorithm



Shahid M. Malik, MD
Shahid M. Malik

Clinical Assistant Professor of Medicine

Division of Gastroenterology, Hepatology and Nutrition

Department of Medicine

Program Director, Transplant Hepatology Fellowship Program

Starzl Transplantation Institute

University of Pittsburgh Medical Center




SMM declares that he has no competing interests.

Kapil B. Chopra, MD, FACP, FAASLD, AGAF
Kapil B. Chopra

Professor of Medicine

Medical Director of Comprehensive Liver Program and Liver Pancreas Institute

University of Pittsburgh School of Medicine

University of Pittsburgh Medical Center




KBC declares that he has no competing interests.

Peer reviewers

Philip Newsome, PhD, FRCPE

Senior Lecturer in Hepatology & Honorary Consultant Physician

Liver Research Group

Institute of Biomedical Research

The Medical School

University of Birmingham




PN declares that he has no competing interests.

Stephen A. Harrison, MD, LTC, MC

Chief of Hepatology

Department of Medicine

Gastroenterology & Hepatology Service

Brooke Army Medical Center

Fort Sam Houston

Associate Professor of Medicine

University of Texas Health Science Center




SAH is an author of a reference cited in this topic.

Robert D. Goldin, MBCHB, MD, FRCPath

Reader in Liver and GI Pathology

Imperial College at St. Mary's




RDG declares that he has no competing interests.

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