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For the liver cirrhosis diagnosis and its complications extensive diagnostic tests and some procedures are done, which can be categorized into- blood tests, imaging studies, and procedures.
These are given below:
– Albumin level decreases in advanced cirrhosis. It checks the ability of the liver to produce a protein called albumin. Levels less than 3.5 g/dL suggest cirrhosis with a likelihood ratio of 4.4.
– Prothrombin time/INR is increased in severe liver damage. It has cirrhosis likelihood ratio of 5
– ALT and AST levels are typically elevated with Liver cirrhosis diagnosis
– Serum LDH level is elevated with liver cirrhosis diagnosis and HCC
– GGT is typically elevated
– Bilirubin level is usually elevated
– Low hemoglobin due to GI bleeding, alcohol toxicity, vitamin deficiency, increased activity of spleen.
– The platelet count is generally low. A count below 1,60,000/mm3 is highly suggestive of cirrhosis.
– Increased levels may suggest the onset of renal dysfunction (hepatorenal syndrome) or excessive use of a diuretic.
Viral markers to test for liver infection caused by viruses
– Hepatitis B surface antigen for hepatitis B infection, if positive anti-HBc and anti-HBs are done.
– Anti-HCV for hepatitis C infection, if positive HCV-RNA is done
Serum biomarkers for assessment of ongoing fibrosis.
– This test is well established for cases of viral hepatitis
– Multiple serum biomarkers are done and the results are used to create a predictive score of fibrosis
– Patented tests such as Fibro Test, Fibro Sure, etc.
– Nonpatented tests, use, the routinely available laboratory tests, eg: AST to platelet test scores.
– Autoimmune markers test: Antinuclear antibodies (ANA), anti-smooth muscle antibodies or anti-LKM-1 antibodies in a person may suggest autoimmune hepatitis as an underlying cause of cirrhosis. It is important to be done in people with risk factors, such as female sex.
– Serum ferritin level and transferrin saturation can be done to rule out hemochromatosis as a cause of cirrhosis.
– Increased serum copper and decreased ceruloplasmin levels can suggest Wilson’s disease. Urine test for copper can also be done which may suggest increased excretion.
• Imaging investigations like ultrasound, CT, and MRI are not reliable for the detection of early cirrhosis.
• Transient elastography can be used for early fibrosis or cirrhosis
• Imaging studies become more reliable in advanced/decompensated cirrhosis.
– It is usually the first imaging test done for Liver cirrhosis diagnosis.
– Often able to detect cirrhosis especially in advanced cases.
– It can evaluate liver vessels for portal hypertension or blockage.
– It can also detect liver cancer (HCC) in many cases especially with large and obvious mass. However, CT or MRI is better in detecting liver cancers.
– Generally, the next imaging is done after positive ultrasound test.
– It gives more information than ultrasound.
– Gives a better picture about associated complications such as collaterals, liver masses especially with Dynamic CT/ Triphasic CT.
– Is done to detect and quantify the amount of fibrosis or scarring in the liver.
– It doesn’t require a needle to be passed through the skin and take a sample of tissue, unlike liver biopsy.
– It uses ultrasound waves to measure the amount of fibrosis in units called kilopascal 15 16
– It grades the fibrosis into following grades ranging from F0, F1, F2, F3 to F4 suggesting increasing grade of stiffness/fibrosis. F0 being no fibrosis to F4 suggesting cirrhosis.
– Best for detecting and differentiating between the lowest and highest grade of fibrosis such as F0, F1 or F4, F5. Low sensitivity in differentiating between F2 or F3.
– The test is avoided in pregnant women and in people with ascites or pacemakers. The accuracy of the test can be affected in obese people.
The Society of Radiologists in Ultrasound recommends using elastography to discriminate no or minimal fibrosis from severe fibrosis or Liver cirrhosis diagnosis.
Ascitic fluid tapping and examination of the fluid in people with ascites is a small amount of fluid taken out of the abdomen with help of a needle and a syringe under aseptic precautions which is then sent for examination.
– Done in people with ascites to confirm portal hypertension as the cause of ascites.
– Done if infection (spontaneous bacterial peritonitis) is suspected
• Contraindicated in cases of disseminated intravascular coagulation (DIC) and hyperfibrinolysis.
• Considered generally safe even with coagulopathy (when INR is 8.7 or less) and platelet count is equal or higher than 19,000/mm³ or higher. Extreme caution is to be taken beyond those levels
• Biopsy is considered as the best test to diagnose and confirm cirrhosis. However, it is usually not required when the liver cirrhosis diagnosis is obvious with clinical findings and other diagnostic tests.
• It can also differentiate between the grades of fibrosis with good accuracy.
• It can indicate the cause of cirrhosis in many cases, which might help in treatment planning eg: Wilson’s disease or hemochromatosis.
• It can also confirm the presence of liver cancer and can help to differentiate between the types of cancer eg: HCC, cholangiocarcinoma, or mixed variety.
Liver Biopsy Procedure:
The procedure involves passing a special needle into the liver to take out a small sample of liver tissue. The needle can be passed through the skin of the abdomen overlying the liver after taking aseptic precautions with the help of imaging techniques such as a USG or CT scan. The needle can also be passed through the jugular vein or with the help of a laparoscope.
• Biopsy leads to pain in up to 84% of people.
• Bleeding: severe bleeding can occur in 1 in 2500 to 1 in 10,000 people with a percutaneous approach. This needs hospitalization and proper treatment.
• Major coagulopathy
• Uncontrolled sepsis
The biopsy results in Liver cirrhosis Diagnosis show fibrosis with regenerative nodules. The degree of fibrosis is assessed by means of scoring systems such as METAVIR histopathologic score 20
The grades of fibrosis are classified as follows:
• F0: no fibrosis
• F1: mild fibrosis
• F2: significant fibrosis
• F3: severe fibrosis
• F4: cirrhosis
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