Last reviewed: 25 Dec 2021
Last updated: 14 May 2021



History and exam

Key diagnostic factors

  • history of cirrhosis
  • history of chronic hepatitis B (HBV) or C (HCV)
  • history of chronic heavy alcohol use
  • history of diabetes or obesity
  • family history of liver cancer
  • older age
  • hepatomegaly

Other diagnostic factors

  • abdominal distention
  • esophageal or gastric variceal bleeding
  • right upper quadrant pain
  • early satiety
  • weight loss
  • leg edema
  • hepatic encephalopathy
  • cachexia
  • jaundice
  • splenomegaly
  • asterixis
  • spider nevi
  • palmar erythema
  • periumbilical collateral veins
  • fetor hepaticus
  • diarrhea
  • paraneoplastic syndrome
  • bone pain
  • severe abdominal pain
  • obstructive jaundice
  • enlarged hemorrhoidal 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
  • thorium dioxide radioactive contrast
  • hemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cholangitis (PBC)
  • primary sclerosing cholangitis
  • androgenic steroids
  • oral contraceptives
  • male sex

Diagnostic investigations

1st investigations to order

  • complete blood count
  • basic metabolic panel
  • liver function tests
  • prothrombin time/international normalized ratio
  • viral hepatitis panel
  • alpha fetoprotein (AFP)
  • ultrasound of liver

Investigations to consider

  • contrast CT scan of abdomen
  • contrast MRI of abdomen
  • liver biopsy
  • computed tomography scan of chest
  • bone scan

Treatment algorithm



Qingyao Daniel Huang, MBBS MMed (Internal Medicine) MRCP

Associate Consultant

Department of Medicine

Division of Gastroenterology & Hepatology

National University Health System



QDN declares that he has no competing interests.


Dr Qingyao Daniel Huang would like to gratefully acknowledge Dr Poh Seng Tan, Dr Badar Muneer and Dr Smruti R. Mohanty, previous contributors to this topic.


PST has received sponsorship/honorarium from Bayer (South East Asia) Pte Ltd and Sirtex for attending conferences, delivering lectures, and participating in advisory board meetings. 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

Srikrishna Nagri, MD


Dartmouth-Hitchcock Nashua




SN declares that he has no competing interests.

Ned Snyder, MD, FACP

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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