Cirrhosis Diagnosis: Blood Tests, Imaging, and Biopsy Evaluation

Cirrhosis—irreversible hepatic fibrosis with nodular regeneration—is diagnosed through a combination of non-invasive assessment and targeted confirmation.

Laboratory Evaluation

Liver Synthetic Function

• Albumin (decreased = impaired synthesis)
• INR/PT (increased = reduced clotting factors)
• Bilirubin (increased = excretory dysfunction)

Liver Injury & Inflammation

• ALT, AST (AST > ALT suggests alcoholic or advanced cirrhosis)
• ALP, GGT (cholestasis/biliary involvement)

Hematologic Markers

• Thrombocytopenia (<150k): splenic sequestration + reduced thrombopoietin
• Leukopenia: hypersplenism, marrow suppression

Etiology Workup

• Hepatitis B: HBsAg, anti-HBc, HBV DNA
• Hepatitis C: anti-HCV, HCV RNA
• Autoimmune: ANA, ASMA, anti-LKM, IgG
• Metabolic: Ferritin, transferrin saturation (hemochromatosis); Ceruloplasmin (Wilson's)
• Alcohol: CDT, PEth, AST:ALT ratio

Non-Invasive Fibrosis Assessment

• FIB-4: (Age × AST) / (Platelets × √ALT) — low <1.3, high >2.67
• APRI: (AST/ULN × 100) / Platelets
• ELF Test: HA, PIIINP, TIMP-1 panel
• Vibration-Controlled Transient Elastography (FibroScan): Liver stiffness (kPa); CAP for steatosis. Gold standard non-invasive test.
• MRI Elastography (MRE): Highest accuracy; less widely available.

Imaging

• Ultrasound: Nodular surface, caudate hypertrophy, splenomegaly, portal vein >13 mm, collaterals, ascites.
• CT/MRI: Superior for HCC screening (every 6 months), vascular anatomy, and varices.

Liver Biopsy

Indicated when: etiology unclear, non-invasive tests discordant, clinical trial enrollment, or pre-transplant evaluation. Risks include pain, bleeding (1/500), and sampling error (10–30%). Staging uses METAVIR/Ishak systems (F4 = cirrhosis).