Last reviewed:August 2019
Last updated:August  2018



History and exam

Key diagnostic factors

  • history of cirrhosis
  • history of chronic hepatitis B (HBV) or C (HCV)
  • history of chronic heavy alcohol use
  • history of diabetes or obesity
  • family history of liver cancer
  • older age
  • hepatomegaly

Other diagnostic factors

  • abdominal distention
  • esophageal or gastric variceal bleeding
  • right upper quadrant pain
  • early satiety
  • weight loss
  • leg edema
  • hepatic encephalopathy
  • cachexia
  • jaundice
  • splenomegaly
  • asterixis
  • spider nevi
  • palmar erythema
  • periumbilical collateral veins
  • fetor hepaticus
  • diarrhea
  • paraneoplastic syndrome
  • bony pain
  • severe abdominal pain
  • obstructive jaundice
  • enlarged hemorrhoidal veins
  • vascular bruit

Risk factors

  • cirrhosis
  • chronic hepatitis B (HBV) infection
  • chronic hepatitis C (HCV) cirrhosis
  • chronic heavy alcohol use
  • diabetes
  • obesity
  • family history of liver cancer
  • aflatoxin
  • Thorotrast radioactive contrast
  • hemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cirrhosis (PBC)
  • primary sclerosing cholangitis
  • androgenic steroids
  • oral contraceptives
  • male sex

Diagnostic investigations

1st investigations to order

  • complete blood count
  • basic metabolic panel
  • liver function tests
  • prothrombin time/international normalized ratio
  • viral hepatitis panel
  • alpha fetoprotein (AFP)
  • ultrasound of liver
Full details

Investigations to consider

  • contrast computed tomography (CT) scan of abdomen
  • contrast magnetic resonance imaging (MRI) of abdomen
  • liver biopsy
  • computed tomography scan of chest
  • bone scan
Full details

Treatment algorithm


Consultant, Gastroenterology & Hepatology

Assistant Professor, Yong Loo Lin School of Medicine

National University of Singapore



PST has received a speaker honorarium from GE Healthcare, Bayer, and Sirtex. PST has received travel and accommodation arrangements for medical conferences from Bristol-Myers Squibb, Gilead, Sirtex, Bayer, and Novartis.

Dr Poh Seng Tan would like to gratefully acknowledge Dr Badar Muneer and Dr Smruti R. Mohanty, previous contributors to this monograph. BM declares that he has no competing interests. SRM serves as a speaker for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewersVIEW ALL


Dartmouth-Hitchcock Nashua




SN declares that he has no competing interests.

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch




NS declares that he has no competing interests.

Use of this content is subject to our disclaimer