Last reviewed: 22 May 2021
Last updated: 15 Oct 2019



History and exam

Key diagnostic factors

  • abdominal pain
  • hepatomegaly
  • hematemesis and melena
  • 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 contracture
  • leg swelling
  • parotid gland enlargement
  • gynecomastia
  • 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)
  • CBC
  • serum electrolytes, magnesium, phosphorus
  • serum BUN 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 antimitochondrial antibody (AMA)
  • serum antinuclear antibody (ANA) and antismooth muscle antibody (ASMA)
  • serum alpha-1 antitrypsin level
  • serum ammonia
  • serum folate
  • CT abdomen, MRI abdomen
  • liver biopsy

Emerging tests

  • serum carbohydrate-deficient transferrin test
  • serum mitochondrial AST
  • noninvasive biomarker panel

Treatment algorithm


Craig McClain


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




CM declares that he has no competing interests.

Luis Marsano

Professor and Director of Hepatology

Division of Gastroenterology, Hepatology and Nutrition

Department of Medicine

University of Louisville School of Medicine




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).

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


MP declares that he has no competing interests.

Peer reviewersVIEW ALL

Postdoctoral Research Associate

Center for Alcohol and Addiction Studies

Brown University




LL declares that he has no competing interests.

Assistant Professor of Medicine

University of Chicago

Center for Liver Disease




NR declares that she has no competing interests.

Head of Clinical Hepatology and Senior Lecturer

Division of Infection, Inflammation and Immunity

University of Southampton Medical School

Southampton General Hospital NHS Trust




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 traveling 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 traveling 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.

Consultant Hepatologist

Royal Infirmary of Edinburgh




AM declares that he has no competing interests.

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