Cirrhosis differential diagnosis: Difference between revisions

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!Differentiating Tests
!Differentiating Tests
|-
|-
|Constrictive pericarditis
|'''Constrictive pericarditis'''
|
|
* Increased [[jugular venous pressure]]  
* Increased [[jugular venous pressure]]  
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* [[Doppler ultrasound]] shows ventricular filling abnormalities
* [[Doppler ultrasound]] shows ventricular filling abnormalities
|-
|-
|Budd-Chiari Syndrome
|'''Budd-Chiari Syndrome'''
|
|
* Abdominal pain
* Abdominal pain
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* Abdominal CT will show a rapid clearing of the caudate lobe of the liver
* Abdominal CT will show a rapid clearing of the caudate lobe of the liver
|-
|-
|Splenic vein thrombosis
|'''Splenic vein thrombosis'''
|Signs and symptoms of:
|Signs and symptoms of:
* Upper abdominal pain radiating to the back
* Upper abdominal pain radiating to the back
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* Normal hepatic venous pressure gradient is present
* Normal hepatic venous pressure gradient is present
|-
|-
|Portal vein thrombosis
|'''Portal vein thrombosis'''
|
|
* Symptoms depend on the underlying cause:
* Symptoms depend on the underlying cause:
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* History generally reveals exposure
* History generally reveals exposure
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|}
{| style="width:80%; height:100px" border="1"
|-
| style="width:10%" bgcolor="LightSteelBlue" ; border="1" | '''Condition'''
| style="width:45%" bgcolor="Beige" ; border="1" | '''Differentiating Signs and Symptoms'''
| style="width:45%" bgcolor="Beige" ; border="1" | '''Differentiating Tests'''
|-
|- bgcolor="LightSteelBlue"
| '''Constrictive pericarditis'''
| bgcolor="Beige" |Increased [[jugular venous pressure]], [[atrial fibrillation]], and [[tachycardia]]. Quiet heart sounds with a third heart sound (ventricular knock) present.
| bgcolor="Beige" |[[EKG]] will show [[tachycardia]], atrial fibrillation, low-voltage QRS complexes and T wave abnormalities. [[Doppler ultrasound]] will show ventricular filling abnormalities.
|-
|- bgcolor="LightSteelBlue"
| '''Budd-Chiari Syndrome'''
| bgcolor="Beige" |[[Abdominal pain]], [[diarrhea]], and worsening [[ascites]].
| bgcolor="Beige" |[[Doppler ultrasound]] and [[CT]] of the abdomen will show absence of the hepatic vein filling. Abdominal CT will show a rapid clearing of the caudate lobe of the liver.
|-
|- bgcolor="LightSteelBlue"
| '''Splenic vein thrombosis'''
| bgcolor="Beige" |Similar signs and symptoms of [[acute pancreatitis]] with upper abdominal pain radiating to the back, vomiting, poor bowel sounds, fever and shock. [[Cullen's sign]] and [[Grey-Turner's sign]] may be present.
| bgcolor="Beige" |An ultrasound of the abdomen and CT will show evidence of a splenic vein thrombosis. Normal hepatic venous pressure gradient is present.
|-
|- bgcolor="LightSteelBlue"
| '''Portal vein thrombosis'''
| bgcolor="Beige" | Will depend on the underlying cause. If pancreatitis is present, upper abdominal pain radiating to the back, vomiting, poor bowel sounds, [[fever]] and [[shock]]. [[Cullen's sign]] and [[Grey-Turner's sign]] may be present. If the cause is [[ascending cholangitis]], fever, [[rigors]], right upper quadrant pain, dark urine, and pale stools may be seen. If abdominal sepsis is the cause, [[fever]], [[abdominal pain]] and other signs of [[peritonitis]] will be seen.
| bgcolor="Beige" |[[Doppler ultrasound]] and abdominal CT will show a portal vein filling defect, and absence of flow in the portal vein. MR or direct angiography will show a normal hepatic venous pressure gradient.
|-
|- bgcolor="LightSteelBlue"
| '''Schistosomiasis'''
| bgcolor="Beige" |History of travel to endemic areas. Constitutional symptoms such as malaise, [[rigors]], [[anorexia]], [[weight loss]], [[vomiting]], [[diarrhea]], [[headache]], muscular aches, [[weakness]] and [[abdominal pain]]. Also [[urticaria]], [[fever]] and [[lymphadenopathy]] may be seen.
| bgcolor="Beige" |MR or direct angiography will show a normal hepatic venous pressure gradient.
|-
|- bgcolor="LightSteelBlue"
| '''Sarcoidosis'''
| bgcolor="Beige" |Dry cough with [[dyspnea]]. Anterior or posterior [[uveitis]], [[dry eyes]] and [[glaucoma]]. Skin findings may include maculopapular lesions on the face, back, arms and legs, and [[erythema nodosum]] on the legs.
| bgcolor="Beige" |Chest x ray may show [[hilar lymphadenopathy]], upper lobe fibrosis, and diffuse reticulonodular shadowing. Liver biopsy will show non-necrotizing, [[non-caseating granulomas]].
|-
|- bgcolor="LightSteelBlue"
| '''Inferior vena cava obstruction'''
| bgcolor="Beige" |Signs and symptoms of [[renal cell carcinoma]], with [[hematuria]], [[flank pain]], flank or abdominal mass, weight loss and [[hypertension]].
| bgcolor="Beige" |Ultrasound of the abdomen will show evidence of inferior vena cava obstruction.
|-
|- bgcolor="LightSteelBlue"
| '''Nodular regenerative hyperplasia'''
| bgcolor="Beige" |None
| bgcolor="Beige" |[[Liver biopsy]] will show small regenerative nodules with little or no fibrosis on reticulin staining.
|-
|- bgcolor="LightSteelBlue"
| '''Idiopathic portal hypertension (hepatoportal sclerosis)'''
| bgcolor="Beige" |None
| bgcolor="Beige" |[[Liver biopsy]] will show no evidence of cirrhosis.
|-
|- bgcolor="LightSteelBlue"
| '''Vitamin A intoxication, arsenic, and vinyl chloride toxicity'''
| bgcolor="Beige" |None
| bgcolor="Beige" |History generally reveals exposure.
|-
|}
===Differentiating Cirrhosis from other Diseases Based on Ascitic Fluid===
===Differentiating Cirrhosis from other Diseases Based on Ascitic Fluid===
[[Ascites]] may be caused by [[portal hypertension]] due to cirrhosis of [[liver]] or due to other causes such as [[Cancer|malignancy]]. [[Ascites|Ascitic]] fluid analysis should be done to broadly categorize the cause of [[ascites]].
[[Ascites]] may be caused by [[portal hypertension]] due to cirrhosis of [[liver]] or due to other causes such as [[Cancer|malignancy]]. [[Ascites|Ascitic]] fluid analysis should be done to broadly categorize the cause of [[ascites]].

Revision as of 15:28, 19 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]}Sudarshana Datta, MD [3]

Overview

Cirrhosis may present in a similar way to some other diseases. History, physical examination, and diagnostic testing may help to differentiate 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 cirrhosis on the basis of jaundice is as follows: [1]

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
Family history Fever RUQ Pain Pruritis AST ALT ALK BLR Indirect BLR Direct Viral serology
Jaundice Hepatocellular Jaundice Hemochromatosis + - -/+ - ↑ ↑ ↑/N ↑/N N - Ferritin ↑ Liver biopsy
Wilson's disease + - -/+ - ↑ ↑ N ↑/N N - Serum cerulloplasmin ↑ 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 platate Small liver on ultrasond
Cholestatic Jaundice Common bile duct stone -/+ - + + N N ↑ N ↑ - Dilated ducts on sono CT/ERCP
Hepatitis A cholestatic type - -/+ + + N N ↑ N ↑ + HAV- AB Abdominal ultrasound
EBV / CMV hepatitis - -/+ + + N N ↑ N ↑ + Positive serology
Primary biliary cirrhosis -/+ - -/+ + N/↑ N/↑ ↑ N ↑ - AMA positive Liver biopsy
Primary sclerosing cholangitis -/+ - -/+ + N/↑ N/↑ ↑ N ↑ - Beading on MRCP Liver biopsy
Pancreatic carcinoma + - -/+ - N/↑ N/↑ ↑ N ↑ - Mass on ultrasond CT scan for diagnosis
Isolated Jaundice Crigler-Najjar type 2 + - - - N N N ↑ ↑ - Genetic testing
Gilbert + - - - 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
Hereditory spherocytosis + - -/+ - N N N ↑ N - Genetic testing Osmotic fragility
G6PD deficiency + - - - N N N ↑ N - Genetic testing
Thalassemia + - - - N N N ↑ N - Genetic testing
Sickle cell disease + - - - N N N ↑ N - Genetic testing
Paroxismal nocturnal hemoglobinoria - - - - N N N ↑ N - Flocytometery
Immune hemolysis - -/+ - - N N N ↑ N - Autoantibodies
Hematoma - -/+ - - N N N ↑ N - Anemia Truma or surgery in history

Differential diagnosis of cirrhosis based on altered hepatic function:

Condition Differentiating signs and symptoms Differentiating Tests
Constrictive pericarditis
Budd-Chiari Syndrome
  • Abdominal pain
  • Diarrhea
  • Ascites
  • Doppler ultrasound and CT of the abdomen shows absence of the hepatic vein filling
  • Abdominal CT will show a rapid clearing of the caudate lobe of the liver
Splenic vein thrombosis Signs and symptoms of:
  • Ultrasound of the abdomen and CT will show evidence of a splenic vein thrombosis
  • Normal hepatic venous pressure gradient is present
Portal vein thrombosis
  • Doppler ultrasound and abdominal CT show a portal vein filling defect, and absence of flow in the portal vein.
  • MR or direct angiography show a normal hepatic venous pressure gradient.
Schistosomiasis
  • MR or direct angiography shows a normal hepatic venous pressure gradient
Sarcoidosis
Inferior vena cava obstruction
  • Ultrasound of the abdomen shows evidence of inferior vena cava obstruction
Nodular regenerative hyperplasia None
  • Liver biopsy shows small regenerative nodules with little or no fibrosis on reticulin staining
Idiopathic portal hypertension (hepatoportal sclerosis) None
Vitamin A intoxication, arsenic, and vinyl chloride toxicity None
  • History generally reveals exposure

Differentiating Cirrhosis from other Diseases Based on Ascitic Fluid

Ascites may be caused by portal hypertension due to cirrhosis of liver or due to other causes such as malignancy. Ascitic fluid analysis should be done to broadly categorize the cause of ascites.

Ascites is broadly classified as two types based on the serum-ascites albumin gradient (SAAG):

References

  1. ↑ Fargo MV, Grogan SP, Saguil A (2017). "Evaluation of Jaundice in Adults". Am Fam Physician. 95 (3): 164–168. PMID 28145671.

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