Diagnostic Approach to the Patient With Cirrhosis

8/10/2019 Diagnostic Approach to the Patient With Cirrhosis

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Diagnostic approach to the patient with cirrhosis

AuthorsEric Goldberg, MDSanjiv Chopra, MD

Section EditorBruce A Runyon, MD

Deputy EditorAnne C Travis, MD, MSc, FACG

All opics are updaed as ne! evidence beco"es available and our peer revie! process isco"plee#

Literature review current through:Sep $%&$# ' This topic last updated:"ar (, $%&$#

)*TR+DCT)+* - Cirrhosis represens a lae sage o. progressive hepaic .ibrosis characeri/edby disorion o. he hepaic archiecure and he .or"aion o. regeneraive nodules# ) is generallyconsidered o be irreversible in is advanced sages a !hich poin he only opion "ay be liverransplanaion# 0o!ever, reversal o. cirrhosis 1in is earlier sages2 has been docu"ened inseveral .or"s o. liver disease .ollo!ing rea"en o. he underlying cause# 3aiens !ih cirrhosis aresuscepible o a variey o. co"plicaions and heir li.e e4pecancy is "ar5edly reduced#

This opic !ill revie! issues relaed o he diagnosis o. cirrhosis# An overvie! o. he co"plicaions,prognosis, and general "anage"en issues is presened separaely# 1See 6+vervie! o. heco"plicaions, prognosis, and "anage"en o. cirrhosis6#2

C7)*)CA7 MA*)FESTAT)+*S - 3aiens !ih cirrhosis "ay presen in a variey o. !ays 8&9#

They "ay have sig"aa o. chronic liver disease discovered on rouine physical

e4a"inaion 1see :3hysical .indings: belo!2 They "ay have undergone laboraory or radiologic esing or an unrelaed surgical

procedure ha incidenally uncovered he presence o. cirrhosis

They "ay presen !ih deco"pensaed cirrhosis, !hich is characeri/ed by he presence o.

dra"aic and li.e;hreaening co"plicaions, such as variceal he"orrhage, ascies,sponaneous bacerial perioniis 1SB32, or hepaic encephalopahy

So"e paiens never co"e o clinical aenion# )n older revie!s, cirrhosis !as diagnosed a

auopsy in up o

3laeles 14&%%%""


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Alanine a"inorans.erase o asparae a"inorans.erase 1A7TAST2 raio> ? /ero poins,

$ o ? one poin, %# o &( !o poins, @%# hree poins

)nernaional nor"ali/ed raio 1)*R2> @& /ero poins, & o = one poin, = !o poins

Facors associaed !ih a lo! li5elihood o. cirrhosis included>

7o5 inde4 @$% percen 17R %#%(2

3laele coun o. &%,%%%""


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Terry:s nails can also be seen in paiens !ih cirrhosis# The pro4i"al !o;hirds o. henail plae appears !hie !hereas he disal one;hird is red# This .inding is also believedo be secondary o a lo! seru" albu"in 8&&9#

Clubbing and hyperrophic oseoarhropahy - Clubbing is presen !hen he angle

be!een he nail plae and pro4i"al nail .old is greaer han &% degrees 1.igure &2# hensevere, he disal .inger has a dru" sic5 appearance# 0yperrophic oseoarhropahy10+A2 is a chronic proli.eraive periosiis o. he long bones ha can cause considerablepain# Clubbing is "ore co""on in biliary causes o. cirrhosis 1paricularly pri"ary biliarycirrhosis2 !hile hyperrophic oseoarhropahy can be seen !ih various causes o. liverdisease 8&$,&


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0epao"egaly - The cirrhoic liver "ay be enlarged, nor"al si/ed, or s"all# hile he

presence o. a palpable liver "ay indicae liver disease, a non;palpable liver does noe4clude i# hen palpable, he cirrhoic liver has a .ir" and nodular consisency#

Spleno"egaly - Spleno"egaly is co""on especially in paiens !ih cirrhosis .ro"

nonalcoholic eiologies 8&9# ) is believed o be caused pri"arily by congesion o. he redpulp as he resul o. poral hyperension# 0o!ever, splenic si/e does no correlae !ell!ih poral pressures, suggesing ha oher .acors "ay be conribuing 8&%9# Thedi..erenial diagnosis o. spleno"egaly includes several oher disorders# 1See 6Approacho he adul paien !ih spleno"egaly and oher splenic disorders6#2

Ascies - Ascies is he accu"ulaion o. .luid in he perioneal caviy# The accuracy o.

physical .indings is variable depending in par upon he a"oun o. .luid presen, heechniue used o e4a"ine he paien, and he clinical seing 1eg, deecion "ay be"ore di..icul in paiens !ho are obese2# )n one sudy, he absence o. .lan5 dullness !ashe "os accurae predicor agains he presence o. asciesH he probabiliy o. asciesbeing presen !as less han &% percen in such paiens 8&(9# 0o!ever, appro4i"aely&%% "7 o. .luid had o be presen .or .lan5 dullness o be deeced# 1See 6Diagnosis andevaluaion o. paiens !ih ascies6#2

Capu "edusae - The veins o. he lo!er abdo"inal !all nor"ally drain in.eriorly ino heilio.e"oral syse" !hile he veins o. he upper abdo"inal !all drain superiorly ino heveins o. he horacic !all and a4illa# hen poral hyperension occurs as he resul o.cirrhosis, he u"bilical vein, nor"ally oblieraed in early li.e, "ay open# Blood .ro" heporal venous syse" "ay be shuned hrough he periu"bilical veins ino he u"bilicalvein and uli"aely o he abdo"inal !all veins, causing he" o beco"e pro"inen# Thisappearance has been said o rese"ble he head 1capu2 o. he "yhical Gorgon Medusa#

Dilaed abdo"inal veins can also be seen in he in.erior vena cava syndro"e 8$%9 andhe superior vena cava syndro"e 1i. obsrucion includes he a/ygous syse"2 8$&9# )nhese condiions, collaeral veins end o be "ore pro"inen in he laeral aspec o. heabdo"inal !all# +ne "aneuver ha has been proposed o disinguish vena cavalobsrucion .ro" poral hyperension is o pass he .inger along dilaed veins

locaedbelowhe u"bilicus o srip he" o. blood and deer"ine he direcion o. blood.lo! during re.illing# )n poral;syse"ic collaeral veins, he blood .lo! should be direcedin.eriorly a!ay .ro" he u"bilicus in conras o vena caval collaeral vein .lo! in !hichhe .lo! should be cephalad# 0o!ever, he acual abiliy o. his "aneuver o discri"inaebe!een he !o is poor since in boh condiions he dilaed veins "ay lac5 valves andhus have bidirecional blood .lo! 8$$9#

Cruveilhier;Bau"garen "ur"ur - The Cruveilhier;Bau"garen "ur"ur is a venous hu"

ha "ay be ausculaed in paiens !ih poral hyperension# ) resuls .ro" collaeralconnecions be!een he poral syse" and he re"nan o. he u"bilical vein# ) is besappreciaed !hen he sehoscope is placed over he epigasriu"# The "ur"ur isaug"ened by "aneuvers !hich increase inraabdo"inal pressure such as he Ialsalva"aneuver and di"inished by applying pressure on he s5in above he u"bilicus 8$


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asy"po"aic hyperbilirubine"ia6#2

Kello! discoloraion o he s5in can also be caused by e4cessive consu"pion o.caroene 1such as in paiens !ho consu"e large uaniies o. carros2# Kello!ing o. hes5in in caroene"ia can be disinguished .ro" jaundice by he absence o. yello!discoloraion in he sclera in he .or"er#

Aseri4is - Aseri4is 1bilaeral bu asynchronous .lapping "oions o. ousreched,dorsi.le4ed hands2 is seen in paiens !ih hepaic encephalopahy, !hich describes hespecru" o. poenially reversible neuropsychiaric abnor"aliies seen in paiens !ihliver dys.uncion# Aseri4is "ay also be seen in paiens !ih ure"ia and severe hear.ailure# 1See 6Clinical "ani.esaions and diagnosis o. hepaic encephalopahy6#2

Miscellaneous - 3aiens !ih cirrhosis "ay also presen !ih a diverse range o. signs and

sy"po"s ha re.lec he pivoal role ha he liver has in he ho"eosasis o. "anydi..eren bodily .uncions# They "ay also have .eaures suggesing he underlying causeo. cirrhosis such as cryoglobuline"ia .ro" hepaiis C, diabees "ellius and arhropahyin paiens !ih he"ochro"aosis, and e4rahepaic auoi""une diseases 1such ashe"olyic ane"ia or hyroidiis2 in paiens !ih auoi""une hepaiis# 1See appropriaeopic revie!s#2

+her general .eaures ha "ay be seen include>

Consiuional sy"po"s such as !ea5ness, .aigue, anore4ia, and !eigh loss and .eaures

suggesing "alnuriion# 3ig"en gallsones resuling .ro" he"olysis 8$9# 1See 6Epide"iology o. and ris5 .acors .or

gallsones6#2

3aroid gland enlarge"en 1probably due o alcohol, no cirrhosis per se2# Enlarge"en is

usually secondary o .ay in.ilraion, .ibrosis, and ede"a raher han a hyper.uncioninggland 8$9#

Diabees "ellius is seen in & o


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in paiens !ih Budd;Chiari syndro"e2, or Riedel:s lobe 1an anao"ical varian in !hich here is ane4ension o. he righ;lobe do!n!ard and laeral o!ard he gallbladder2#

7aboraory .indings - The presence o. cirrhosis is so"ei"es suggesed by laboraoryabnor"aliies# )n oday:s "edical pracice, i is co""on .or panels o. seru" che"isries o be sen.or screening or evaluaion o. speci.ic co"plains# Alhough he er" 6liver .uncion ess6 17FTs2 is

co""only used, i is i"precise since "any o. he ess re.lecing he healh o. he liver are no direc"easures o. is .uncion#

The "os co""on laboraory "easures classi.ied as 7FTs include he en/y"e ess 1principally heseru" a"inorans.erases, al5aline phosphaase, and ga""a glua"yl ranspepidase2, he seru"bilirubin, and ess o. synheic .uncion 1principally he seru" albu"in concenraion andprohro"bin i"e2#

Cerain abnor"aliies discovered on rouine cell couns and che"isries can sugges he presenceo. advanced liver disease !hile providing clues o is severiy and eiology# 1See 6Approach o hepaien !ih abnor"al liver .uncion ess6#2

Several noninvasive ess .or diagnosis o. cirrhosis have been proposed bu none has ye e"erged

as a sandard# *everheless, hey can provide adjuncive in.or"aion o convenional laboraoryesing# 1See 6*oninvasive assess"en o. hepaic .ibrosis6#2

A"inorans.erases - Asparae a"inorans.erase 1AST2 and alanine a"inorans.erase

1A7T2 are usually "oderaely elevaed# AST is "ore o.en elevaed han A7T# 0o!ever,nor"al a"inorans.erases do no preclude a diagnosis o. cirrhosis 8


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3rohro"bin i"e - The liver is involved in he synhesis o. "any o. he proeins reuired

.or nor"al cloing# Thus, he prohro"bin i"e re.lecs he degree o. hepaic synheicdys.uncion# The prohro"bin i"e increases as he abiliy o. a cirrhoic liver o synhesi/ecloing .acors di"inishes# 1See 6Tess o. he liver:s biosynheic capaciy 1eg, albu"in,coagulaion .acors, prohro"bin i"e26#2

Globulins - Globulins end o be increased in paiens !ih cirrhosis# This "ay be

secondary o shuning o. bacerial anigens in poral venous blood a!ay .ro" he liver oly"phoid issue !hich induces i""unoglobulin producion 8


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"ajor uiliy o. radiography in he evaluaion o. he cirrhoic paien is in is abiliy o deecco"plicaions o. cirrhosis such as ascies, hepaocellular carcino"a, and hepaic or poral veinhro"bosis# )n rare insances, radiographic .indings sugges he eiology o. cirrhosis# Ahyperrophied caudae lobe discovered on CT scanning, .or e4a"ple, suggess Budd;Chiarisyndro"e 8=&9# Decreased signal inensiy on MR) "ay indicae iron overload .ro" herediaryhe"ochro"aosis 1picure


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*uclear sudies - Radionuclide esing can be use.ul in suggesing he diagnosis o.

cirrhosis 8


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3rophylacic "easures 1such as la"ivudine or hepaiis B i""une globulin2 are reuired in

paiens undergoing ransplanaion .or cirrhosis relaed o hepaiis B# 1See 67iverransplanaion .or chronic hepaiis B virus in.ecion6#2

Fa"ily "e"bers o. paiens diagnosed !ih he"ochro"aosis or ilson:s disease "ay

reuire geneic counseling and screening# Appropriae prevenive "easures and advicecan be discussed !ih .a"ily "e"bers o. paiens !ih chronic viral hepaiis or alcoholiccirrhosis# 1See appropriae opic revie!s#2

The ris5 .or hepaocellular carcino"a is higher in paiens !ih cirrhosis .ro" viral hepaiis

or he"ochro"aosis co"pared o paiens !ih auoi""une hepaiis or *AS0 8$9# 1See6Epide"iology and eiologic associaions o. hepaocellular carcino"a6#2

Morphologic classi.icaion - Cirrhosis !as hisorically classi.ied "orphologically as "icronodular,"acronodular, or "i4ed 8


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chronic 0BI in.ecion is based upon he deecion o. 0BsAg "ore han .our o si4"onhs a.er iniial in.ecion# Addiional ess .or 0BI replicaion - 0BeAg and seru"0BI D*A- should be per.or"ed o deer"ine i. he paien should be considered .oraniviral herapy# 1See 6Serologic diagnosis o. hepaiis B virus in.ecion6#2

*onalcoholic seaohepaiis - *onalcoholic seaohepaiis 1*AS02 is a disorder

diagnosed by liver biopsy# The biopsy .indings are indisinguishable .ro" hose o.alcoholic hepaiis described above bu he paien lac5s a hisory o. signi.ican alcoholconsu"pion# The liver disease is sable in "os paiens bu a "inoriy progress ocirrhosis# 1See 6Epide"iology, clinical .eaures, and diagnosis o. nonalcoholic .ay liverdisease in aduls6#2

3ri"ary biliary cirrhosis - 3aiens !ih pri"ary biliary cirrhosis 13BC2 "ay be

asy"po"aic or presen !ih a hisory o. .aigue, prurius, and s5in hyperpig"enaionha is no due o jaundice# The physical e4a"inaion ypically reveals hepao"egaly andless o.en spleno"egaly# 7aboraory ess reveal pronounced elevaions in he seru"al5aline phosphaase concenraion, !hich is o. hepaic originH a..eced paiens "ay alsohave sri5ing elevaions in he seru" choleserol concenraion !hile hyperbilirubine"iais no seen unil lae in he course o. he disease# Modes elevaions in seru" bilirubinha persiss .or "ore han hree o si4 "onhs i"ply a poor prognosisH such paiens

should be re.erred .or liver ransplanaion even in he absence o. li.e;hreaeningco"plicaions relaed o cirrhosis# 1See 6Clinical "ani.esaions, diagnosis, and nauralhisory o. pri"ary biliary cirrhosis6#2

Ani"iochondrial anibodies are he serologic hall"ar5 o. 3BC# 1See 63ahogenesis o.pri"ary biliary cirrhosis6#2 The E7)SA ess are ( percen sensiive and ( percenspeci.ic .or 3BC# 7iver biopsy is usually con.ir"aory raher han diagnosic# Thepahogno"onic .lorid bile duc lesion is unco""only seen in percuaneous needlebiopsies o. he liver 1picure (A;B2# The coninuous assaul on he bile duc epihelial cellsleads o heir gradual desrucion and evenual disappearance#

)"aging ess or cholangiography are no needed in "os paiens# Endoscopicrerograde cholangiography is ypically nor"al or sho!s narro! caliber bile ducs in 3BC,

and is help.ul in he paien in !ho" he ani"iochondrial anibody es is negaive andhe possibiliy o. pri"ary sclerosing cholangiis or a carcino"a o. he bile duc orpancreas e4iss#

3ri"ary sclerosing cholangiis - 3ri"ary sclerosing cholangiis 13SC2 is a chronic

cholesaic disease o. he liver and bile ducs ha is .reuenly progressive# The clinicalpresenaion is ha o. a cholesaic liver disease, including prurius, seaorrhea, .asoluble via"in de.iciencies, and "eabolic bone disease# Co"plicaions are co""on,including do"inan biliary sricures, cholangiis, cholelihiasis, cholangiocarcino"a, andcolon cancer# 1See 6Clinical "ani.esaions and diagnosis o. pri"ary sclerosingcholangiis6#2

There is a srong associaion be!een 3SC and in.la""aory bo!el disease, paricularlyulceraive coliis 1C2 bu also Crohn:s disease# The incidence o. C in paiensapproaches (% percen !hen recal and sig"oid biopsies are rouinely obained# 1See6Epide"iology and pahogenesis o. pri"ary sclerosing cholangiis6#2

The diagnosis is bes esablished by conras cholangiography, !hich reveals acharacerisic picure o. di..use, "uli.ocal sricures and .ocal dilaion o. he bile ducs,leading o a beaded appearance 1picure &%2# The er" 6pri"ary6 is used o disinguish3SC .ro" oher condiions ha "ay lead o a si"ilar clinical and cholangiographicsyndro"e# These include choledocholihiasis, cholangiocarcino"a, bacerial cholangiis,prior biliary surgery, inraarerial .lo4uridine, and acuired i""unode.iciency syndro"e


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associaed cholangiopahy#

3SC is also associaed !ih a nu"ber o. i""unologic abnor"aliies, none o. !hich isdiagnosic# These include an elevaed seru" )gM concenraion in % percen andseveral auoanibodies# The "os co""on are ani;s"ooh "uscle and aninuclearanibodies, and anibodies direced agains cyoplas"ic and nuclear anigens o.neurophils# 1See 6Epide"iology and pahogenesis o. pri"ary sclerosing cholangiis6#2

Auoi""une hepaiis - Esablishing he diagnosis o. auoi""une hepaiis is paricularly

i"poran because herapy !ih prednisone !ih or !ihou a/ahioprine is bene.icial#Many paiens, even hose !ih esablished cirrhosis, respond !hen rea"en is iniiaed#1See 6Trea"en o. auoi""une hepaiis6#2

A characerisic laboraory .eaure o. auoi""une hepaiis, alhough no universallypresen, is an elevaion in seru" globulins, paricularly ga""a globulins# Thishyperglobuline"ia is generally associaed !ih circulaing auoanibodies, !hich areparicularly help.ul in ideni.ying auoi""une hepaiis# There are !o "ajor ypes o.auoi""une hepaiis !hich are characeri/ed by speci.ic auoanibodies> aninuclear,ani;s"ooh "uscle, aniacin anibodies andor A*CA in ype &H and ani;7M;& and ani;

A7C;& 1ani;liver cyosol2 anibodies in ype $ 1able $2# +n occasion, ani"iochondrial

anibodies occur in associaion !ih aninuclear andor s"ooh "uscle anibodies# 1See6Clinical "ani.esaions and diagnosis o. auoi""une hepaiis6#2

The diagnosis o. auoi""une hepaiis can be di..icul o esablish because hecharacerisic auoanibodies "ay be presen and he liver biopsy reveals characerisicbu nonspeci.ic changes such as a poral "ononuclear cell in.ilrae !hich invades hesharply de"arcaed hepaocye boundary 1li"iing plae2 surrounding he poral riadHplas"a cells are o.en seen in he in.la""aory in.ilrae 1picure &&2# Given he possibledi..iculies in diagnosis, so"e clinicians !ill iniiae a rial o. coricoseroids in paiens!ih a co"paible picure and no oher apparen cause o. cirrhosis, paricularly i. heseru" a"inorans.erases are elevaed and pro"inen hyperglobuline"ia is presen#

0erediary he"ochro"aosis - The presence o. herediary he"ochro"aosis 1002 "ay be

suspeced i. here is a .a"ily hisory o. cirrhosis or i. he paien also has s5inhyperpig"enaion, diabees "ellius, pseudogou, andor a cardio"yopahy# 1See6Clinical "ani.esaions o. herediary he"ochro"aosis6#2

Signs o. iron overload are also ypically presen in 00# A .asing rans.errin sauraion o.N% percen in "en and N% percen in !o"en !ill deec abou (% percen o. paiens!ih ho"o/ygous 00# 0o!ever, "any invesigaors have advocaed using a 6cuo..6value o. = percen .or boh "en and !o"en, !hich !ill lead o .e!er paiens being"issed 1a he e4pense o. leading o he ideni.icaion o. "ore .alse posiives2#

)ncreased iron also si"ulaes he hepaic producion and release o. .erriin# As a resul, aplas"a .erriin concenraion above geneic esing, !hich is no! availableH liver biopsyH and he response ouaniaive phleboo"y# )n he absence o. geneic esing, liver biopsy is usually reuiredo con.ir" he diagnosis o. ho"o/ygous 00H heero/ygoes do no develop cirrhosis in
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he absence o. so"e oher ype o. liver disease 1eg, viral hepaiis, nonalcoholicseaohepaiis2# 1See 63ahophysiology and diagnosis o. iron overload syndro"es6 and6Clinical "ani.esaions o. herediary he"ochro"aosis6#2

3arenchy"al iron loading can be de"onsraed by 3erls: 3russian blue saining o. a liverbiopsy, and .ibrosis can be deeced i. i e4iss 1picure 2# The hepaic issue can also bedirecly analy/ed .or iron conen !hich "us be per.or"ed "eiculously o deecnonhe"e iron# The hepaic iron conen is pre.erably repored as "icro"oles o. iron pergra" dry !eigh o. liver# *or"al values are less han Cirrhosis 1Beyond he Basics262


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SMMARK A*D REC+MME*DAT)+*S

3aiens !ih cirrhosis "ay presen in a variey o. !ays and !ih varied clinical .indings# The

hisory and physical e4a"inaion can provide clues as o he presence o. cirrhosis andsugges an eiology# 1See :Clinical "ani.esaions: above#2

Rouine laboraory ess are generally no diagnosic bu can sugges he presence o. liver

disease# )n advanced sages here "ay be an elevaed prohro"bin i"e and oalbilirubin, and a reduced plaele coun and seru" albu"in# e sugges obaining, a a"ini"u", a co"plee blood coun and di..erenial, oal bilirubin, albu"in, and seru"a"inorans.erase levels# Addiional esing "ay be !arraned !hen speci.ic .or"s o. liverdisease are suspeced 1see belo!2#

Radiographic .indings can occasionally sugges he presence o. cirrhosis bu are no

adeuaely sensiive or speci.ic .or use as a pri"ary diagnosic "odaliy# The "ajor uiliyo. radiography in he evaluaion o. paiens !ih cirrhosis is in is abiliy o deecco"plicaions o. cirrhosis such as ascies, hepaocellular carcino"a, and hepaic orporal vein hro"bosis# )n rare insances, radiographic .indings sugges he eiology o.cirrhosis# 1See :Radiographic .indings: above#2

Cirrhosis has radiionally been con.ir"ed !ih a liver biopsy during !hich a sa"ple o. he

liver is obained by eiher a percuaneous, ransjugular, laparoscopic, or radiographically;guided .ine;needle approach depending upon he clinical seing# The sensiiviy o. a liverbiopsy .or cirrhosis is in he range o. % o &%% percen depending upon he "ehodused, and he si/e and nu"ber o. speci"ens obained# 1See :Con.ir"ing ha he paienhas cirrhosis: above#2

Several noninvasive ess .or diagnosis o. cirrhosis have been proposed bu none has ye

e"erged as a sandard# *everheless, hey can provide adjuncive in.or"aion oconvenional laboraory esing and in so"e seings "ay replace a liver biopsy# 1See6*oninvasive assess"en o. hepaic .ibrosis6#2

) is i"poran o esablish he cause o. cirrhosis since i has a bearing on rea"en and

prognosis# The order and selecion o. speci.ic ess .or deer"ining he cause o. cirrhosis

should be guided by he available in.or"aion .ro" he hisory, physical e4a"inaion, andlaboraory and radiologic ess, !hich "ay poin o!ard a diagnosis#

Co""only used panels o. serologic screening ess include assess"en .or chronichepaiis B and C 10BsAg, 0BsAb, 0CI ab2, auoi""une hepaiis 1aninuclear and ani;s"ooh "uscle anibodies2, he"ochro"aosis 1Fe, .erriin and oal iron bindingcapaciy2, pri"ary biliary cirrhosis 1ani"iochondrial anibodies2, and ilson:s disease1seru" ceruloplas"in2# e co""only obain a righ upper uadran ulrasound o assess.or .eaures suggesive o. liver disease and o e4clude biliary obsrucion# As noedabove, a liver biopsy re"ains he re.erence sandard .or esablishing he presence o.cirrhosis and can also help uncover is cause# 1See :Tesing .or speci.ic diseases: above#2

se o. pToDae is subjec o he Subscripion and 7icense Agree"en#

REFERENCES

&Runyon BA# A 3ri"er on Deecing Cirrhosis and Caring .or These 3aiens !ihou Causing0ar"# )n J 0epaol $%&&H $%&&>%&(


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CASES# J Chronic Dis &(=H &?>(

Diseases o. he 7iver, ?h ediion, Schi.. 7, Schi.. E 1Eds2,7ippenco Co"pany, 3hiladelphia &(( resuls o. he 0A7T;C cohor# 0epaology $%%H =$>$$#

?3irovino M, 7inder R, Boss C, e al# Cuaneous spider nevi in liver cirrhosis> capillary"icroscopical and hor"onal invesigaions# lin ochenschr &(H >$(#

Qa"an A, 0ap5e R, Flora , e al# Facors predicing he presence o. esophageal or gasricvarices in paiens !ih advanced liver disease# A" J Gasroenerol &(((H (=> correlaion !ih he"orrhage .ro" esophageal varices# A" J Gasroenerol &(H?$$%


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$3erides AS, Iog C, Schul/e;Berge D, e al# 3ahogenesis o. glucose inolerance and diabees"ellius in cirrhosis# 0epaology &((=H &(>

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Diagnostic Approach to the Patient With Cirrhosis

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