Summary
Definition
History and exam
Key diagnostic factors
- abdominal distension
- jaundice and pruritus
- blood in vomit (hematemesis) and black stool (melena)
- hand and nail features (e.g., leukonychia, palmar erythema, spider nevi)
- facial features, e.g., telangiectasia, spider nevi, jaundiced sclera
- abdominal features (e.g., collateral circulation, hepatosplenomegaly, distension)
- altered mental status
Other diagnostic factors
- constitutional symptoms
- lower extremity swelling
- hepatic fetor
- muscle wasting
- peripheral edema
- recurrent infections
- decreased libido
- chest wall features (e.g., gynecomastia)
- dyspnea
- chest pain
- syncope
Risk factors
- alcohol misuse
- intravenous drug use
- unprotected intercourse
- obesity
- country of birth
- blood transfusion
- tattooing
Diagnostic investigations
1st investigations to order
- liver function tests
- gamma-glutamyl transferase (GGT)
- serum albumin
- serum sodium
- serum potassium
- prothrombin time
- platelet count
- antibodies to hepatitis C virus
- hepatitis B surface antigen ± hepatitis B DNA assay
Investigations to consider
- total iron, total iron binding capacity (TIBC), transferrin saturation, and serum ferritin
- antinuclear antibody
- antismooth muscle antibody
- antimitochondrial antibody
- serum immunoglobulins
- serum ceruloplasmin
- plasma alpha-1 antitrypsin
- alpha-fetoprotein
- abdominal ultrasound
- abdominal CT
- abdominal MRI
- upper gastrointestinal endoscopy
- liver biopsy
- noninvasive tests of liver elasticity
Treatment algorithm
all patients
Contributors
Authors
Apostolos Koffas, MD (AUTH), MRCP (UK)
Clinical Research Fellow
Barts Liver Centre
Barts and the London School of Medicine and Dentistry
London
UK
Disclosures
AK declares that he has no competing interests.
Patrick T. F. Kennedy, MB, BCh, BAO, BMedSci, FRCP, MD
Professor and Consultant Hepatologist
Barts Liver Centre
Barts and the London School of Medicine and Dentistry
London
UK
Disclosures
PTFK acts as an advisor for Gilead Sciences, Janssen, and Immunocore. PTFK has received grant funding from Gilead Sciences. These roles are unrelated to the current article.
Acknowledgements
Dr Apostolos Koffas and Professor Patrick T. F. Kennedy would like to gratefully acknowledge Dr Grace E. Dolman, Dr Keith D. Lindor, and Dr Flavia Mendes, previous contributors to this topic.
Disclosures
GED declares that she has no competing interests. KDL is an unpaid advisor for Intercept Pharmaceuticals and Shire Pharmaceuticals. FM declares that she has no competing interests.
Peer reviewers
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.
Cynthia Levy, MD
Clinical Assistant Professor
Division of Gastroenterology Hepatology and Nutrition
University of Florida
Gainesville
FL
Disclosures
CL declares that she has no competing interests.
James Neuberger, DM, FRCP, Hon
Consultant Physician
Hon Professor in Medicine
Associate Medical Director NHSBT
Queen Elizabeth Hospital
Birmingham
UK
Disclosures
JN declares that he has no competing interests.
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