Cirrhosis differential diagnosis

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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]

Overview

Cirrhosis can present in a similar way to some other diseases. History, physical examination, and diagnostic testing can 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

Condition	Differentiating Signs and Symptoms	Differentiating Tests
Constrictive pericarditis	Increased jugular venous pressure, atrial fibrillation, and tachycardia. Quiet heart sounds with a third heart sound (ventricular knock) present.	EKG will show tachycardia, atrial fibrillation, low-voltage QRS complexes and T wave abnormalities. Doppler ultrasound will show ventricular filling abnormalities.
Budd-Chiari Syndrome	Abdominal pain, diarrhea, and worsening ascites.	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.
Splenic vein thrombosis	Similar signs and symptoms of 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.	An ultrasound of the abdomen and CT will show evidence of a splenic vein thrombosis. Normal hepatic venous pressure gradient is present.
Portal vein thrombosis	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 cholagitis, 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.	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.
Schistosomiasis	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.	MR or direct angiography will show a normal hepatic venous pressure gradient.
Sarcoidosis	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.	Chest x ray may show hilar lymphadenopathy, upper lobe fibrosis, and diffuse reticulonodular shadowing. Liver biopsy will show non-necrotizing, non-caseating granulomas.
Inferior vena cava obstruction	Signs and symptoms of renal cell carcinoma, with hematuria, flank pain, flank or abdominal mass, weight loss and hypertension.	Ultrasound of the abdomen will show evidence of inferior vena cava obstruction.
Nodular regenerative hyperplasia	None	Liver biopsy will show small regenerative nodules with little or no fibrosis on reticulin staining.
Idiopathic portal hypertension (hepatoportal sclerosis)	None	Liver biopsy will show no evidence of cirrhosis.
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 like malignancies etc.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):

• Transudate - SAAG > 1.1 g/dL (indicates the ascites is due to portal hypertension).
• Exudate - SAAG < 1.1 g/dL (indicates the ascites is due to non-portal hypertension etiology).