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The Rational Clinical Examination
February 22/29, 2012

Does This Patient With Liver Disease Have Cirrhosis?

Author Affiliations

Author Affiliations: TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (Dr Udell); Gastroenterology Division, Department of Medicine, Sunnybrook Health Sciences Centre, and University of Toronto, Toronto, Ontario, Canada (Drs Wang and Tinmouth); Gastroenterology Division, Department of Medicine, Brantford General Hospital, Brantford, Ontario, Canada (Dr Wang); Respirology Division, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada (Drs FitzGerald and Ayas); Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver (Drs FitzGerald, Ayas, and Schulzer); Department of Medicine, Durham Veterans Affairs Medical Center, Duke University, Durham, North Carolina (Dr Simel); Pacific Parkinson Research Centre, University of British Columbia, Vancouver (Mr Mak); and Gastroenterology Division, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver (Dr Yoshida) Drs Udell and Wang are coprimary authors.

JAMA. 2012;307(8):832-842. doi:10.1001/jama.2012.186
Abstract

Context Among adult patients with liver disease, the ability to identify those most likely to have cirrhosis noninvasively is challenging.

Objective To identify simple clinical indicators that can exclude or detect cirrhosis in adults with known or suspected liver disease.

Data Sources We searched MEDLINE and EMBASE (1966 to December 2011) and reference lists from retrieved articles, previous reviews, and physical examination textbooks.

Study Selection We retained 86 studies of adequate quality that evaluated the accuracy of clinical findings for identifying histologically proven cirrhosis.

Data Extraction Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality. Random-effects meta-analyses were used to calculate summary LRs across studies.

Results Among the 86 studies, 19 533 patients were included in this meta-analysis, among whom 4725 had biopsy-proven cirrhosis (prevalence rate, 24%; 95% CI, 20%-28%). Many physical examination and simple laboratory tests increase the likelihood of cirrhosis, though the presence of ascites (LR, 7.2; 95% CI, 2.9-12), a platelet count <160 × 103/μL (LR, 6.3; 95% CI, 4.3-8.3), spider nevi (LR, 4.3; 95% CI 2.4-6.2), or a combination of simple laboratory tests with the Bonacini cirrhosis discriminant score >7 (LR, 9.4; 95% CI, 2.6-37) are the most frequently studied, reliable, and informative results. For lowering the likelihood of cirrhosis, the most useful findings are a Lok index <0.2 (a score created from the platelet count, serum aspartate aminotransferase and alanine aminotransferase, and prothrombin international normalized ratio; LR, 0.09; 95% CI, 0.03-0.31); a platelet count ≥160 × 103/μL (LR, 0.29; 95% CI, 0.20-0.39); or the absence of hepatomegaly (LR, 0.37; 95% CI, 0.24-0.51). The overall impression of the clinician was not as informative as the individual findings or laboratory combinations.

Conclusions For identifying cirrhosis, the presence of a variety of clinical findings or abnormalities in a combination of simple laboratory tests that reflect the underlying pathophysiology increase its likelihood. To exclude cirrhosis, combinations of normal laboratory findings are most useful.

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