Cirrhosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Cirrhosis may present in a similar way to some other diseases. History, physical examination, and diagnostic testing may help in differentiating cirrhosis from other diseases such as malignancy, constrictive pericarditis, Budd-Chiari syndrome, portal vein thrombosis and splenic vein thrombosis.

Differentiating Cirrhosis From Other Diseases

Differential diagnosis of jaundice

Differential diagnosis of jaundice are enlisted in the table below:[1][2][3][4][5]

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
Family history Fever Right upper quadrant (RUQ) Pain Pruritis Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) ALK Bilirubin (Indirect) Bilirubin (Direct) Viral serology
Jaundice Hepatocellular Jaundice Liver infiltration: Hemochromatosis, amyloidosis + - -/+ - ↑/N ↑/N N - Ferritin ↑ in hemochromatosis Liver biopsy
Wilson's disease + - -/+ - N ↑/N N - Serum ceruloplasmin Liver biopsy
Viral hepatitis - -/+ - - N ↑/N N + Specific viral antibody for each type -
Alcoholic hepatitis - -/+ -/+ - ↑↑ N ↑/N N - - -
Drug induced hepatitis - -/+ - - N ↑/N N - - -
Autoimmune hepatitis -/+ - - -/+ N ↑/N N - Anti-LKM antibody Liver biopsy
Cirrhosis -/+ -/+ -/+ - ↑/N ↑/N ↑/N -/+ Low platelet count Small liver on ultrasound
Nonalcoholic steatohepatitis -/+ - - - N ↑/N N - High lipids Liver biopsy
Ischemic hepatopathy -/+ - -/+ - N ↑/N N - Cardiovascular risk factors Clinical setting
Cholestatic Jaundice Common bile duct stone -/+ - + + N N N - Dilated ducts on sonography CT scan/ERCP
Hepatitis A (cholestatic type) - -/+ + + N N N + Anti-HAV antibody Abdominal ultrasound
EBV / CMV hepatitis - -/+ + + N N N + Positive serology -
Primary biliary cirrhosis -/+ - -/+ + N/↑ N/↑ N - Antimitochondrial antibody (AMA) positive Liver biopsy
Primary sclerosing cholangitis -/+ - -/+ + N/↑ N/↑ N - Positive autoantibodies (p-ANCA) Beading on MRCP,

Liver biopsy

Sickle cell disease + - - +/- N/↑ N/↑ N - Genetic testing
Pancreatic carcinoma + - -/+ -/+ N/↑ N/↑ N - - CT scan for diagnosis
AIDS cholangiopathy - - -/+ -/+ N/↑ N/↑ N - Positive HIV Sonography or ERCP for diagnosis
Parasite induces cholestasis - - -/+ -/+ N/↑ N/↑ N - Antibodies or parasite serology Sonography or ERCP for diagnosis
Intrahepatic cholestasis of pregnancy -/+ - -/+ + N - Low platelets, Negative viral serology Diagnosed clinically
Isolated Jaundice Crigler-Najjar type 2 + - - - N N N - Genetic testing
Gilbert syndrome + - - - N N N - Genetic testing
Rotor syndrome + - - - N N N N - Genetic testing Liver biopsy
Dubin-Johnson syndrome + - - - N N N N - Genetic testing Liver biopsy
Hereditary spherocytosis + - -/+ - N N N N - Genetic testing Osmotic fragility
Glucose 6 phosphate dehydrogenase (G6PD) deficiency + - - - N N N N - Genetic testing
Thalassemia + - - - N N N N - Genetic testing
Paroxysmal nocturnal hemoglobinuria (PNH) - - - - N N N N - Flow cytometery
Immune hemolysis - -/+ - - N N N N - Autoantibodies
Hematoma - -/+ - - N N N N - Anemia Trauma or surgery in history

Differentiating cirrhosis from other diseases based on serum-ascites albumin gradient (SAAG)

Cirrhosis must be differentiated from other causes of abnormal liver function tests, altered liver architecture and size:

Condition Differentiating signs and symptoms Differentiating Tests
Cirrhosis

Ultrasound findings in cirrhosis are as follows:[6][7][8][9][10][11][12][13]

Abdominal MRI may also be helpful in the diagnosis of portal hypertension. Findings on MRI suggestive of cirrhosis with portal hypertension include:[14][15][16][17]

Transient elastography and the Acoustic Radiation Force Impulse (ARFI) technique are well-established methods for the staging of fibrosis in various liver diseases: [18][19][20][21][22][23][24][25][26][27][28] 

  • The FibroScan (transient elastography) uses elastic waves to determine liver stiffness which theoretically may be converted into a liver score.
  • The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa).
  • Transient elastography is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless.
  • Findings on transient elastography may show reasonable correlation with the severity of cirrhosis:[29][30]
Constrictive pericarditis
Budd-Chiari Syndrome
Splenic vein thrombosis Signs and symptoms of:
Portal vein thrombosis
Schistosomiasis
Sarcoidosis
Inferior vena cava obstruction
Nodular regenerative hyperplasia None
Idiopathic portal hypertension (hepatoportal sclerosis) None
Vitamin A intoxication, arsenic, and vinyl chloride toxicity None
  • History generally reveals exposure

References

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  2. Leevy CB, Koneru B, Klein KM (1997). "Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease". Gastroenterology. 113 (3): 966–72. PMID 9287990. 
  3. Hov JR, Boberg KM, Karlsen TH (2008). "Autoantibodies in primary sclerosing cholangitis". World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433Freely accessible. PMID 18609700. 
  4. Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). "Gall stones in sickle cell disease in the United Kingdom". Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079Freely accessible. PMID 3115390. 
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