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DOES THIS PATIENT HAVE LIVER CIRRHOSIS? THE DIAGNOSTIC UTILITY OF THE HISTORY, PHYSICAL EXAMINATION, AND ROUTINE LABORATORY TESTS
CS Wang, JA Udell, JM Tinmouth, E Mak, M Schulzer, NT Ayas, JM FitzGerald, EM Yoshida
INTRODUCTION: Cirrhosis and chronic liver disease are leading causes of morbidity and mortality; yet the ability to accurately predict cirrhosis clinically remains a challenge. Our objective was to determine the usefulness of clinical indicators on history and physical examination, along with routine laboratory studies, for identifying cirrhosis in adult patients with known or suspected liver disease.
METHODS: We searched MEDLINE (1966 to July 2007) and reference lists from retrieved articles, previous reviews, and physical examination textbooks. We retained studies that evaluated the accuracy of various findings for predicting histologically proven cirrhosis in adult patients with liver disease of any etiology. Two authors independently abstracted data and assessed methodological quality using predetermined criteria. Random-effects meta-analyses were used to calculate summary likelihood ratios (LR) across studies.
RESULTS: The search strategy yielded 3284 citations. Of these, 345 full-text articles were reviewed to yield 68 articles that met eligibility criteria. The best features that increased the probability of cirrhosis included the presence of: (1) History and Physical: ascites (LR+ 8.8; 95% CI, 3.2-14.4), spider nevi (LR+ 4.1; 2.5-5.8); (2) Routine Labs: platelet count < 100-110 × 109 /L (LR+ 7.2; 2.9-11.4), abnormal prothombin time (LR+ 4.6, 1.8-7.4); (3) Combined Indices: AST-to-platelet ratio index (APRI) > 2 (LR+ 5.9; 3.8-7.9), AST/ALT ratio (AAR) > 1 (LR+ 1.5; 0.61-2.5). The features that best decreased the probability of cirrhosis included the absence of: (1) History and Physical: firm liver (LR- 0.33; 0.24-0.41), spider nevi (LR- 0.60; 0.50-0.70); (2) Routine Labs: platelet count < 180-200 × 109 /L (LR- 0.32; 0.08-0.55), abnormal prothombin time (LR- 0.55; 0.31-0.79); (3) Combined Indices: APRI > 1 (LR- 0.30; 0.10-0.50); AAR > 1 (LR- 0.75; 0.44-1.1). The overall clinical gestalt of the clinician was associated with a high positive LR (5.2; 2.3-8.0) and low negative LR (0.50; 0.26-0.74).
CONCLUSIONS: Physical signs and routine laboratory studies are useful for suggesting the presence or absence of cirrhosis; however, diagnostic certainty requires additional testing. Our findings may assist in better selecting patients for further more specialized (and expensive) non-invasive tests and/or liver biopsy.