Last reviewed: February 2019
Last updated: November  2017



History and exam

Key diagnostic factors

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

Other diagnostic factors

  • RUQ abdominal discomfort
  • pruritus
  • jaundice
  • spider angioma
  • palmar erythema
  • nail changes
  • Dupuytren contracture
  • bruising
  • petechiae
  • excoriations
  • gynecomastia
  • parotid gland enlargement
  • testicular atrophy
  • alopecia
  • caput medusae
  • Cruveilhier-Baumgarten murmur
  • peripheral edema
  • ascites
  • low blood pressure
  • hepatic encephalopathy
  • fetor hepaticus
  • hematemesis
  • melena

Risk factors

  • obesity
  • insulin resistance or diabetes
  • dyslipidemia
  • 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 AST and ALT
  • total bilirubin
  • alkaline phosphatase
  • gamma glutamyl transferase
  • CBC
  • metabolic panel
  • lipid panel
  • PT and INR
  • serum albumin
  • ANA and antismooth muscle antibody
  • iron studies
Full details

Investigations to consider

  • fasting insulin
  • homeostasis 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
  • EGD
  • EEG
  • portal venous pressure measurements
  • liver biopsy
Full details

Emerging tests

  • elastography
  • cytokeratin-18 fragments
Full details

Treatment algorithm


Authors VIEW ALL

Shahid M. Malik

Assistant Professor of Medicine

Division of Gastroenterology, Hepatology and Nutrition

Associate Program Director

Transplant Hepatology Fellowship Program

Department of Medicine

University of Pittsburgh Medical Center




SMM declares that he has no competing interests.

Kapil B. Chopra

Professor of Medicine

Medical Director of Comprehensive Liver Program and Liver Pancreas Institute

Program Director of Transplant Hepatology Fellowship Program

University of Pittsburgh School of Medicine

University of Pittsburgh Medical Center




KBC declares that he has no competing interests.

Peer reviewers VIEW ALL

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.

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 monograph.

Reader in Liver and GI Pathology

Imperial College at St. Mary's




RDG declares that he has no competing interests.

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