Work up the etiology

Top tips:

  1. The three most common causes of cirrhosis are Non-alcoholic fatty liver disease, Alcohol and Hepatitis C virus
  2. In addition to a detailed history, examination and liver imaging such as an ultrasound doppler, basic testing in all patients with cirrhosis should include screening with the anti-HCV antibody (will require HCV PCR to confirm diagnosis if antibody is positive), HBsAg, quantitative immunoglobulins and iron studies

Order panels Liver disease work up

For adults:
Liver disease work up 

Dr. Zeman cartoon

Check out the bottom of the page for short videos from Dr. Zeman!

Cirrhosis Etiologies

Most common:

  • Nonalcoholic Fatty Liver Disease (NAFLD)
  • Alcohol related liver disease
  • Chronic viral hepatitis (Hepatitis B, C)

Less common causes (not all inclusive):

  • Autoimmune hepatitis
  • Hereditary Hemochromatosis
  • Primary biliary cholangitis (PBC)
  • Primary sclerosing cholangitis (PSC)
  • Wilsons disease
  • Alpha-1 antitrypsin deficiency

Etiology Considerations

History:

  • Alcohol: Alcohol use (>2 standard drinks/day for women and >3 for men where a standard drink is 10-14 grams of alcohol)
  • Non-alcoholic fatty liver disease: Diabetes or metabolic syndrome
  • Viral hepatitis: Exposures (place of birth, travel, sexual behaviours, drug use, incarceration)
  • Medications and supplement use are unlikely to cause cirrhosis, but can contribute to acute deterioration – see link to Livertox website to evaluate risk and injury pattern of high-risk medications or medications started within the previous 6 months.
  • Autoimmune hepatitis, Primary biliary cholangitis: Family history or personal history of other autoimmune conditions
  • Primary sclerosing cholangitis: Co-existing Inflammatory bowel disease
  • Genetic liver diseases (Wilsons, Alpha-1-antitrypsin deficiency, Hemochromatosis): Family history of cirrhosis (age of onset, etiology), hemochromatosis, premature emphysema
  • History of congestive heart disease

Pattern of liver tests:

  • Hepatocellular (Predominantly high AST/ALT compared to ALP)
  • Cholestatic (Predominantly high ALP compared to AST/ALT)

Link to R-Factor for Liver Injury calculator when you are working up worsening liver enzymes to determine if the pattern is hepatocellular, cholestatic or mixed.

Initial Lab investigations

In addition to a detailed history and relevant physical examination, the following laboratory investigations can be done to determine the etiology in cases of confirmed cirrhosis (image courtesy of Dr. Kelly Burak):

 Introducing Dr. Zeman

Video 1 - The top tips that may be useful for you to know about this page as a family physician including: Investigations to order while waiting for a specialist appointment; and When you need to call a specialist more urgently.

References:

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors: Michelle Carbonneau NP, Dr. Marilyn Zeman, Dr. Aldo Montano-Loza, Dr. Kelly Burak, Dr. Puneeta Tandon

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