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The Rational Clinical Examination |

Does This Patient With Liver Disease Have Cirrhosis?

Jacob A. Udell, MD, MPH, FRCPC; Charlie S. Wang, MD, MSc, FRCPC; Jill Tinmouth, MD, PhD, FRCPC; J. Mark FitzGerald, MB, FRCPC; Najib T. Ayas, MD, MPH, FRCPC; David L. Simel, MD, MHS; Michael Schulzer, MD, PhD; Edwin Mak, BASc; Eric M. Yoshida, MD, MHSc, FRCPC
JAMA. 2012;307(8):832-842. doi:10.1001/jama.2012.186.
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Published online

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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Figure 1. Spider Nevi Lesions on the Upper Chest
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(Photo credit: Kirby Lau/University of British Columbia)
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Figure 2. Direction of Blood Flow in Distended Abdominal Wall Veins
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Figure 3. Definition of the Aspartate Aminotransferase:Platelet Ratio Index, Bonacini Cirrhosis Discriminant Score, and Lok Index
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The Rational Clinical Examination
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The Rational Clinical Examination
Original Article: Does This Patient With Liver Disease Have Cirrhosis?

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