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Last reviewed: 4 Sep 2023
Last updated: 03 Oct 2023



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
More key diagnostic factors

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
Other diagnostic factors

Risk factors

  • alcohol misuse
  • intravenous drug use
  • unprotected intercourse
  • obesity
  • country of birth
  • blood transfusion
  • tattooing
More risk factors

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
More 1st investigations to order

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
More investigations to consider

Treatment algorithm


all patients



Apostolos Koffas, MD (AUTH), MRCP (UK)

Clinical Research Fellow

Barts Liver Centre

Barts and the London School of Medicine and Dentistry




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




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.


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.


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




NR declares that she has no competing interests.

Cynthia Levy, MD

Clinical Assistant Professor

Division of Gastroenterology Hepatology and Nutrition

University of Florida




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




JN declares that he has no competing interests.

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