Note to readers: I excerpt from resources I review because it helps me retain the information and because it makes resources I’ve reviewed easy for me to find via my website’s search function.

#100: Cirrhosis: Initial Evaluation and Management [Link is to the show notes and pocast]
JUNE 18, 2018 By CYRUS ASKIN from The Curbsiders

All that follows is from the above resource.

Shear wave elastography: Can effectively diagnosis cirrhosis in thin patients with hepatitis C. More useful for negative predictive value in obese patients with diabetes and/or fatty liver disease (i.e. a negative test is reassuring, but an intermediate or high risk test needs liver biopsy to confirm). –Dr Matherly

Red flags on lab testing:  Low albumin, low platelets, and/or prolonged INR. –Dr Matherly

Screen for varices in cirrhosis at the time of diagnosis. Subsequent testing every 1-3 years based on size. -Dr Matherly

Screen for hepatocellular carcinoma with hepatic ultrasound every 6 months after a diagnosis of cirrhosis. Alpha fetoprotein was removed from the guidelines, but some experts still use it to augment screening. -Dr Matherly

Diet: High protein diet (at least 1 gm/kg body weight/day) is recommended due to cirrhosis being a catabolic state. Low sodium diet is not useful for cirrhotics unless ascites is present. -Dr Matherly

In-depth Show Notes

The seven hand findings of cirrhosis: 

1. Palmar Erythema¹
2. Dupuytren’s contracture²
3. Asterixis ³
4. Terry’s Nails ⁴
5. Clubbing ⁵
6. Spider angiomas ⁶
7. Muscle wasting ^7.

4. Terry’s Nails: A Sign of Systemic Disease. Indian J Dermatol. 2017 May-Jun; 62(3): 309–311. doi: 10.4103/ijd.IJD_98_17

5. Evaluation of clubbing, summary, BMJ Best Practice, Last updated: 31 Jan 2023.

5. Clubbing of the nails, etiology, epidemiology, emedicine.medscape.com. Updated: Mar 23, 2021 Author: Robert A Schwartz, MD, MPH

6. Spider Angiomas, StatPearls, Last Update: July 19, 2022.

Laboratory Assessment – AST, ALT & Beyond¹

1. Excerpts From The 2017 Guidelines On The Evaluation Of Abnormal Liver Tests From The ACG
Posted on April 26, 2019 by Tom Wade MD

1. Normal ALT – most lab values are NOT evidence based ⁸
   1. Female: 19-25 IU/L
   2. Male: 29-33 IU/L
2. Thrombocytopenia: an immediate red flag when evaluating a patient for liver disease (<150×10⁹) ⁹
   1. This may indicate advanced disease as the thrombocytopenia is often due to portal hypertension, which develops in the setting of cirrhosis and leads to splenic sequestration of platelets/ hypersplenism
3. Albumin: hypoalbuminemia due to liver disease suggests advanced liver disease ¹⁰
4. PT/INR: One of the most sensitive markers for hepatic function, elongated INR suggests advanced liver disease, readily available virtually anywhere ¹¹
5. FIB-4: First developed for estimating degree of fibrosis in HIV/HCV co-infection; later found to be more generalizable. Useful when imaging is not already available, to screen patients when there is concern for cirrhosis ¹²
   1. FIB-4=Age×ASTPLT×ALT
   2. <1.45 has NPV of 90% for advanced fibrosis (sens. 81%)
   3. >3.25 has PPV of 65% for advanced fibrosis (sens. 97%)
   4. Fib4, and other non-invasive tests, are “good at the margins” – indeterminate scores need to be invasively evaluated – Dr. Matherly
6. Don’t forget hepatitis C testing!
   1. HCV: If born 1945-1965, CDC recommends Hep C testing ¹³

Beyond Blood Tests

1. Shear-wave elastography/vibration controlled transient elastography ¹⁴
   1. Non-invasive means to determine “liver stiffness” and from there, extrapolate extent of fatty infiltration and/or fibrosis
   2. Dr. Matherly: “Essentially replaced liver biopsy (in hepatitis C)”
   3. Fatty liver disease: negative predictive tool
2. Ultrasound: with respect to fibrosis shows changes when disease is advanced, not useful for identifying early fibrosis ¹⁵
3. Liver biopsy: the gold standard, limited by sampling bias ^16,17

Cirrhosis can kill you in three ways

1. Liver failure
   1. Check & trend MELD scores 1  ¹⁸

1. Links To And Excerpts From “The Evolution of the MELD Score and Its Implications in Liver Transplant Allocation: A Beginner’s Guide for Trainees”
Posted on February 11, 2023 by Tom Wade MD

1. Variceal Bleeding ¹⁹
   1. > ¼ patients who have an index variceal bleed will die of variceal bleeding
   2. Baveno VI: PLT > 150 and shear-wave elastography demonstrating liver stiffness < 20 kPa, EGD can be circumvented as risk of varices is < 5%^19,20
   3. EGD is gold standard ¹⁹
      1. Allows you to quantify and characterize varices
      2. If no varices: repeat in 3 years
      3. Small varices: repeat EGD every 1-2 years
   4. It boils down to how large they are (correlates with bleeding risk)
2. Hepatocellular carcinoma ²¹
   1. Risk of liver cancer in a cirrhotic is anywhere from 3-5% per year
   2. Ultrasound surveillance every 6 months following initial diagnosis

Sources

1. Serrao R, Zirwas M, English JC. Palmar erythema. Am J Clin Dermatol. 2007;8(6):347-56.
2. Davidson CS, Summerskill WH, Wolfe SJ. Thickening and contraction of the palmar fascia (Dupuytren’s contracture) associated with alcoholism and hepatic cirrhosis. N Engl J Med. 1956;255(12):559-63.
3. Butz M, Timmermann L, Gross J, et al. Cortical activation associated with asterixis in manifest hepatic encephalopathy. Acta Neurol Scand. 2014;130(4):260-7.
4. Baran B, Soyer OM, Karaca C. Terry’s nail: an overlooked physical finding in cirrhosis. HBPD INT. 2013;12(1):109.
5. Callemeyn J, Van haecke P, Peetermans WE, Blockmans D. Clubbing and hypertrophic osteoarthropathy: insights in diagnosis, pathophysiology, and clinical significance. Acta Clin Belg. 2016;71(3):123-30.
6. Li CP, Lee FY, Hwang SJ, et al. Spider angiomas in patients with liver cirrhosis: role of vascular endothelial growth factor and basic fibroblast growth factor. World J Gastroenterol. 2003;9(12):2832-5.
7. Montano-loza AJ. Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol. 2014;20(25):8061-71.
8. Kwo PY, Cohen SM, Lim JK. ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol. 2017;112(1):18-35.
9. Gangireddy VG, Kanneganti PC, Sridhar S, Talla S, Coleman T. Management of thrombocytopenia in advanced liver disease. Can J Gastroenterol Hepatol. 2014;28(10):558-64.
10. Spinella R, Sawhney R, Jalan R. Albumin in chronic liver disease: structure, functions and therapeutic implications. Hepatol Int. 2016;10(1):124-32.
11. Schuppan D, Afdhal N. Liver cirrhosis. Lancet. 2008;371: 838-51.
12. Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology. 2006;43(6):1317-25.
13. Testing Recommendations for Hepatitis C Infection. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm. Last update 10/2015. Accessed 6/2018.
14. De lédinghen V, Vergniol J. Transient elastography (FibroScan). Gastroenterol Clin Biol. 2008;32(6 Suppl 1):58-67.
15. Saverymuttu SH, Joseph AE, Maxwell JD. Ultrasound scanning in the detection of hepatic fibrosis and steatosis. Br Med J (Clin Res Ed). 1986;292(6512):13-5.
16. Germani G, Hytiroglou P, Fotiadu A, Burroughs AK, Dhillon AP. Assessment of fibrosis and cirrhosis in liver biopsies: an update. Semin Liver Dis. 2011;31(1):82-90.
17. Rockey D, et al. Liver Biopsy. 2009 position paper by the American Association for the study of liver diseases. Hepatology 2009;49(3):1017-43
18. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464-70.
19. Garcia-tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310-335.
20. De franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743-52.
21. Heimbach J, Kulik L, et al. Guidelines for the Treatment of Hepatocellular Carcinoma: 2018 practice guidance by the American Association for the study of liver diseases. Hepatology. 2018;67(1):358-80.