Cirrhosis differential diagnosis

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

Overview

Cirrhosis may present in a similar way to some other diseases. History, physical examination, and diagnostic testing may help in differentiating 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 jaundice

Differential diagnosis of jaundice are enlisted in the table below:^[1]^[2]^[3]^[4]^[5]

Classification of jaundice based on etiology		Disease	History and clinical manifestations				Diagnosis
			History and clinical manifestations				Lab Findings						Other blood tests	Other diagnostic
			Family history	Fever	Right upper quadrant (RUQ) Pain	Pruritis	Aspartate aminotransferase (AST)	Alanine aminotransferase (ALT)	ALK	Bilirubin (Indirect)	Bilirubin (Direct)	Viral serology	Other blood tests	Other diagnostic
Jaundice	Hepatocellular Jaundice	Liver infiltration: Hemochromatosis, amyloidosis	+	–	-/+	–	↑	↑	↑/N	↑/N	N	–	Ferritin ↑ in hemochromatosis	Liver biopsy
		Wilson’s disease	+	–	-/+	–	↑	↑	N	↑/N	N	–	Serum ceruloplasmin ↑	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 platelet count	Small liver on ultrasound
		Nonalcoholic steatohepatitis	-/+	–	–	–	↑	↑	N	↑/N	N	–	High lipids	Liver biopsy
		Ischemic hepatopathy	-/+	–	-/+	–	↑	↑	N	↑/N	N	–	Cardiovascular risk factors	Clinical setting
	Cholestatic Jaundice	Common bile duct stone	-/+	–	+	+	N	N	↑	N	↑	–	Dilated ducts on sonography	CT scan/ERCP
		Hepatitis A (cholestatic type)	–	-/+	+	+	N	N	↑	N	↑	+	Anti-HAV antibody	Abdominal ultrasound
		EBV / CMV hepatitis	–	-/+	+	+	N	N	↑	N	↑	+	Positive serology	–
		Primary biliary cirrhosis	-/+	–	-/+	+	N/↑	N/↑	↑	N	↑	–	Antimitochondrial antibody (AMA) positive	Liver biopsy
		Primary sclerosing cholangitis	-/+	–	-/+	+	N/↑	N/↑	↑	N	↑	–	Positive autoantibodies (p-ANCA)	Beading on MRCP, Liver biopsy
		Sickle cell disease	+	–	–	+/-	N/↑	N/↑	↑	N	↑	–	Genetic testing
		Pancreatic carcinoma	+	–	-/+	-/+	N/↑	N/↑	↑	N	↑	–	–	CT scan for diagnosis
		AIDS cholangiopathy	–	–	-/+	-/+	N/↑	N/↑	↑	N	↑	–	Positive HIV	Sonography or ERCP for diagnosis
		Parasite induces cholestasis	–	–	-/+	-/+	N/↑	N/↑	↑	N	↑	–	Antibodies or parasite serology	Sonography or ERCP for diagnosis
		Intrahepatic cholestasis of pregnancy	-/+	–	-/+	+	↑	↑	↑	N	↑	–	Low platelets, Negative viral serology	Diagnosed clinically
	Isolated Jaundice	Crigler-Najjar type 2	+	–	–	–	N	N	N	↑	↑	–	Genetic testing
		Gilbert syndrome	+	–	–	–	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
		Hereditary spherocytosis	+	–	-/+	–	N	N	N	↑	N	–	Genetic testing	Osmotic fragility
		Glucose 6 phosphate dehydrogenase (G6PD) deficiency	+	–	–	–	N	N	N	↑	N	–	Genetic testing
		Thalassemia	+	–	–	–	N	N	N	↑	N	–	Genetic testing
		Paroxysmal nocturnal hemoglobinuria (PNH)	–	–	–	–	N	N	N	↑	N	–	Flow cytometery
		Immune hemolysis	–	-/+	–	–	N	N	N	↑	N	–	Autoantibodies
		Hematoma	–	-/+	–	–	N	N	N	↑	N	–	Anemia	Trauma or surgery in history

Differentiating cirrhosis from other diseases based on serum-ascites albumin gradient (SAAG)

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):
- Transudate – SAAG > 1.1 g/dL (indicative of ascites due to portal hypertension)
- Exudate – SAAG < 1.1 g/dL (indicative of ascites due to other etiologies)

Cirrhosis must be differentiated from other causes of abnormal liver function tests, altered liver architecture and size:

Condition	Differentiating signs and symptoms	Differentiating Tests
Cirrhosis	Abdominal pain and bloating Menstrual irregularities Symptoms of hypogonadism: Impotence Infertility Testicular atrophy Loss of libido Easy bruisability Decompensated cirrhosis may present with Jaundice Increase in abdominal girth due to ascites Pruritus Signs of upper gastrointestinal bleeding: Hematemesis Hematochezia Melena Symptoms due to hepatic encephalopathy: Altered mental status Confusion Sleep disturbances	Ultrasound findings in cirrhosis are as follows:^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13] Changes in liver contour: shrunken, irregular appearance Non homogeneous appearance of the hepatic tissue Increased surface nodularity Increase in echogenecity from focal fatty infiltration Atrophy of the right lobe and hypertrophy of the caudate or left lobe Splenomegaly Ascites Varices Hepatic or portal vein thrombosis Abdominal MRI may also be helpful in the diagnosis of portal hypertension. Findings on MRI suggestive of cirrhosis with portal hypertension include:^[14]^[15]^[16]^[17] Cirrhotic liver, as shrinkage and atrophy in liver Re-canalized umbilical vein—pathognomonic Dilated portal vein and/or splanchnic veins Esophageal varices Collaterals in any abdominal organ Splenomegaly Ascites Transient elastography and the Acoustic Radiation Force Impulse (ARFI) technique are well-established methods for the staging of fibrosis in various liver diseases: ^[18]^[19]^[20]^[21]^[22]^[23]^[24]^[25]^[26]^[27]^[28] The FibroScan (transient elastography) uses elastic waves to determine liver stiffness which theoretically may be converted into a liver score. The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa). Transient elastography is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless. Findings on transient elastography may show reasonable correlation with the severity of cirrhosis:^[29]^[30] Increasing scarring of the liver is associated with increasing “stiffness” of the tissue.
Constrictive pericarditis	Increased jugular venous pressure Atrial fibrillation Tachycardia Faint heart sounds with a third heart sound (ventricular knock)	EKG will show: Tachycardia Atrial fibrillation Low-voltage QRS complexes T wave abnormalities Doppler ultrasound shows ventricular filling abnormalities
Budd-Chiari Syndrome	Abdominal pain Diarrhea Ascites	Doppler ultrasound and CT of the abdomen shows absence of the hepatic vein filling Abdominal CT scan will show a rapid clearing of the caudate lobe of the liver
Splenic vein thrombosis	Signs and symptoms of: Upper abdominal pain radiating to the back Vomiting Hypoactive bowel sounds Fever Shock Cullen’s sign Grey-Turner’s sign	Ultrasound of the abdomen and CT scan will show evidence of a splenic vein thrombosis Normal hepatic venous pressure gradient is present
Portal vein thrombosis	Symptoms depend on the underlying cause: If pancreatitis is present, the patient may develop: Upper abdominal pain radiating to the back Vomiting Hypoactive bowel sounds fever shock Cullen’s sign Grey-Turner’s sign If the cause is ascending cholangitis, symptoms include: Fever Rigors Right upper quadrant pain Dark urine Pale stools If abdominal sepsis is the cause, symptoms include: Fever Abdominal pain Signs of peritonitis	Doppler ultrasound and abdominal CT scan 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	Patients may have a history of travel to endemic areas Constitutional symptoms such as Malaise Rigors Anorexia Weight loss Vomiting Diarrhea Headache Muscular aches Weakness Abdominal pain Urticaria Fever Lymphadenopathy	MR or direct angiography shows a normal hepatic venous pressure gradient
Sarcoidosis	Dry cough with dyspnea Anterior or posterior uveitis Dry eyes glaucoma Skin findings may include: Maculopapular lesions on the face, back, arms and legs Erythema nodosum on the legs	Chest x ray may show: Hilar lymphadenopathy Upper lobe fibrosis Diffuse reticulonodular shadowing Liver biopsy shows non-necrotizing, non-caseating granulomas
Inferior vena cava obstruction	Signs and symptoms of renal cell carcinoma: Hematuria Flank pain Flank or abdominal mass Weight loss Hypertension	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	Liver biopsy shows no evidence of cirrhosis
Vitamin A intoxication, arsenic, and vinyl chloride toxicity	None	History generally reveals exposure

Differentiating Cirrhosis from other causes of jaundice and abdominal pain

Cirrhosis must be differentiated from other diseases that cause jaundice, abdominal pain, weight loss, and fever such as Gallbladder cancer, hepatocellular carcinoma, pancreatic cancer, cholecystitis, choledochitis and liver fluke infections.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging
Disease	Clinical manifestations													Diagnosis		Comments
	Symptoms									Signs				Diagnosis
Cholangiocarcinoma	RUQ	+	−	+	+	−	−	+	−	−	−	+	Normal	Elevated CA 19-9 Increased amylase / lipase Increased stool fat content	Contrast-enhanced ultrasound CT scan Calcification Pseudocyst Dilation of main pancreatic duct MRI	Predisposes to pancreatic cancer
Hepatocellular carcinoma/Metastasis	RUQ	+	−	+	+	+	+	+	+	+	−	+	Normal Hyperactive if obstruction present	High levels of AFP in serum Abnormal liver function tests Thrombocytopenia	US CT MRI Liver biopsy	Other symptoms: Splenomegaly Variceal bleeding Ascites Spider nevi Asterixis
Pancreatic carcinoma	MidEpigastric	−	−	+	+	+	−	+	−	−	−	+	Normal	↑ Alkaline phosphatase ↑ serum bilirubin ↑ gamma-glutamyl transpeptidase ↑ CA 19-9	MDCT with PET/CT MRI EUS	Skin manifestations may include: Bullous pemphigoid Cicatricial pemphigoid Migratory superficial thrombophlebitis (classic Trousseau’s syndrome) Pancreatic panniculitis
Focal nodular hyperplasia	Diffuse	±	−	−	±	−	−	+	+	−	−	−	Normal	Normal Liver function tests Normal AFP Minor elevations of Aspartate Alanine aminotransferase Alkaline phosphatase Gamma glutamyl transpeptidase	Us Multiphasic helical CT scan	Open biopsy if diagnosis can not be established
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Gallbladder cancer	Midepigastric	−	−	+	+	−	+	+	−	−	−	−	Normal	↑ Alkaline phosphatase ↑ CA 19-9	US CT MRI
Liver hemangioma	Intermittent RUQ	−	−	+	+	−	−	−	−	−	−	−	Normal	Abnormal LFTs	US Single-photon emission computerized tomography(SPECT) MRI	US will reveal hypoechoic lesions
Liver abscess	RUQ	+	−	+	+	−	−	+	−	−	−	−	Normal	Hypoalbuminemia Abnormal liver function tests	US CT
Cirrhosis	RUQ+Bloating	+	−	+	+	−	−	+	−	−	−	−	Normal	Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia	US Nodular, shrunken liver Ascites	Stigmata of liver disease Cruveilhier- Baumgarten murmur
Inflammatory lesions	RUQ	±	−	+	+	−	−	−	−	−	−	−	Normal	Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia	US Nodular,shrunken or coarse liver	Stigmata of liver disease

References

↑ Fargo MV, Grogan SP, Saguil A (2017). “Evaluation of Jaundice in Adults”. Am Fam Physician. 95 (3): 164–168. PMID 28145671.
↑ Leevy CB, Koneru B, Klein KM (1997). “Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease”. Gastroenterology. 113 (3): 966–72. PMID 9287990.
↑ Hov JR, Boberg KM, Karlsen TH (2008). “Autoantibodies in primary sclerosing cholangitis”. World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433. PMID 18609700.
↑ Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). “Gall stones in sickle cell disease in the United Kingdom”. Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079. PMID 3115390.
↑ Malakouti M, Kataria A, Ali SK, Schenker S (2017). “Elevated Liver Enzymes in Asymptomatic Patients – What Should I Do?”. J Clin Transl Hepatol. 5 (4): 394–403. doi:10.14218/JCTH.2017.00027. PMC 5719197. PMID 29226106.
↑ Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM (2012). “Does this patient with liver disease have cirrhosis?”. JAMA. 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834.
↑ Becker CD, Scheidegger J, Marincek B (1986). “Hepatic vein occlusion: morphologic features on computed tomography and ultrasonography”. Gastrointest Radiol. 11 (4): 305–11. PMID 3533689.
↑ Di Lelio A, Cestari C, Lomazzi A, Beretta L (1989). “Cirrhosis: diagnosis with sonographic study of the liver surface”. Radiology. 172 (2): 389–92. doi:10.1148/radiology.172.2.2526349. PMID 2526349.
↑ Sanford NL, Walsh P, Matis C, Baddeley H, Powell LW (1985). “Is ultrasonography useful in the assessment of diffuse parenchymal liver disease?”. Gastroenterology. 89 (1): 186–91. PMID 3891495.
↑ Giorgio A, Amoroso P, Lettieri G, Fico P, de Stefano G, Finelli L, Scala V, Tarantino L, Pierri P, Pesce G (1986). “Cirrhosis: value of caudate to right lobe ratio in diagnosis with US”. Radiology. 161 (2): 443–5. doi:10.1148/radiology.161.2.3532188. PMID 3532188.
↑ Simonovský V (1999). “The diagnosis of cirrhosis by high resolution ultrasound of the liver surface”. Br J Radiol. 72 (853): 29–34. doi:10.1259/bjr.72.853.10341686. PMID 10341686.
↑ Trinchet JC, Chaffaut C, Bourcier V, Degos F, Henrion J, Fontaine H, Roulot D, Mallat A, Hillaire S, Cales P, Ollivier I, Vinel JP, Mathurin P, Bronowicki JP, Vilgrain V, N’Kontchou G, Beaugrand M, Chevret S (2011). “Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities”. Hepatology. 54 (6): 1987–97. doi:10.1002/hep.24545. PMID 22144108.
↑ “EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma”. J. Hepatol. 56 (4): 908–43. 2012. doi:10.1016/j.jhep.2011.12.001. PMID 22424438.
↑ Procopet, Bogdan; Berzigotti, Annalisa (2017). “Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy”. Gastroenterology Report. 5 (2): 79–89. doi:10.1093/gastro/gox012. ISSN 2052-0034.
↑ Aagaard, J; Jensen, LI; Sorensen, TI; Christensen, U; Burcharth, F (1982). “Recanalized umbilical vein in portal hypertension”. American Journal of Roentgenology. 139 (6): 1107–1110. doi:10.2214/ajr.139.6.1107. ISSN 0361-803X.
↑ Cho, K C; Patel, Y D; Wachsberg, R H; Seeff, J (1995). “Varices in portal hypertension: evaluation with CT”. RadioGraphics. 15 (3): 609–622. doi:10.1148/radiographics.15.3.7624566. ISSN 0271-5333.
↑ Bandali, Murad Feroz; Mirakhur, Anirudh; Lee, Edward Wolfgang; Ferris, Mollie Clarke; Sadler, David James; Gray, Robin Ritchie; Wong, Jason Kam (2017). “Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy”. World Journal of Gastroenterology. 23 (10): 1735. doi:10.3748/wjg.v23.i10.1735. ISSN 1007-9327.
↑ Castera L, Pinzani M (2010). “Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango?”. Gut. 59 (7): 861–6. doi:10.1136/gut.2010.214650. PMID 20581229.
↑ Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E (2012). “Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis”. J. Viral Hepat. 19 (2): e212–9. doi:10.1111/j.1365-2893.2011.01537.x. PMID 22239521.
↑ Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E (2008). “Performance of transient elastography for the staging of liver fibrosis: a meta-analysis”. Gastroenterology. 134 (4): 960–74. doi:10.1053/j.gastro.2008.01.034. PMID 18395077.
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↑ Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R (2003). “Transient elastography: a new noninvasive method for assessment of hepatic fibrosis”. Ultrasound Med Biol. 29 (12): 1705–13. PMID 14698338.
↑ Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D’Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F (2013). “EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology”. Ultraschall Med. 34 (2): 169–84. doi:10.1055/s-0033-1335205. PMID 23558397.
↑ “EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis”. J. Hepatol. 63 (1): 237–64. 2015. doi:10.1016/j.jhep.2015.04.006. PMID 25911335.
↑ Castera L, Bedossa P (2011). “How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy?”. Liver Int. 31 Suppl 1: 13–7. doi:10.1111/j.1478-3231.2010.02380.x. PMID 21205132.
↑ Chou R, Wasson N (2013). “Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review”. Ann. Intern. Med. 158 (11): 807–20. doi:10.7326/0003-4819-158-11-201306040-00005. PMID 23732714.
↑ Khallafi H, Qureshi K (2015). “Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach”. Interdiscip Perspect Infect Dis. 2015: 809289. doi:10.1155/2015/809289. PMC 4686715. PMID 26779260.
↑ Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA (2013). “Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis”. Clin. Gastroenterol. Hepatol. 11 (12): 1573–84.e1–2, quiz e88–9. doi:10.1016/j.cgh.2013.07.034. PMC 3900882. PMID 23954643.
↑ Foucher J, Chanteloup E, Vergniol J; et al. (2006). “Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study”. Gut. 55 (3): 403–8. doi:10.1136/gut.2005.069153. PMID 16020491.
↑ Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X (2012). “Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B”. Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine. 31 (7): 1053–60. PMID 22733854.

Template:WS Template:WH

[pmid28145671-1] Fargo MV, Grogan SP, Saguil A (2017). “Evaluation of Jaundice in Adults”. Am Fam Physician. 95 (3): 164–168. PMID 28145671.

[pmid9287990-2] Leevy CB, Koneru B, Klein KM (1997). “Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease”. Gastroenterology. 113 (3): 966–72. PMID 9287990.

[pmid18609700-3] Hov JR, Boberg KM, Karlsen TH (2008). “Autoantibodies in primary sclerosing cholangitis”. World J. Gastroenterol. 14 (24): 3781–91. PMC 2721433. PMID 18609700.

[pmid3115390-4] Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ (1987). “Gall stones in sickle cell disease in the United Kingdom”. Br Med J (Clin Res Ed). 295 (6592): 234–6. PMC 1247079. PMID 3115390.

[pmid29226106-5] Malakouti M, Kataria A, Ali SK, Schenker S (2017). “Elevated Liver Enzymes in Asymptomatic Patients – What Should I Do?”. J Clin Transl Hepatol. 5 (4): 394–403. doi:10.14218/JCTH.2017.00027. PMC 5719197. PMID 29226106.

[pmid22357834-6] Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM (2012). “Does this patient with liver disease have cirrhosis?”. JAMA. 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834.

[pmid3533689-7] Becker CD, Scheidegger J, Marincek B (1986). “Hepatic vein occlusion: morphologic features on computed tomography and ultrasonography”. Gastrointest Radiol. 11 (4): 305–11. PMID 3533689.

[pmid2526349-8] Di Lelio A, Cestari C, Lomazzi A, Beretta L (1989). “Cirrhosis: diagnosis with sonographic study of the liver surface”. Radiology. 172 (2): 389–92. doi:10.1148/radiology.172.2.2526349. PMID 2526349.

[pmid3891495-9] Sanford NL, Walsh P, Matis C, Baddeley H, Powell LW (1985). “Is ultrasonography useful in the assessment of diffuse parenchymal liver disease?”. Gastroenterology. 89 (1): 186–91. PMID 3891495.

[pmid3532188-10] Giorgio A, Amoroso P, Lettieri G, Fico P, de Stefano G, Finelli L, Scala V, Tarantino L, Pierri P, Pesce G (1986). “Cirrhosis: value of caudate to right lobe ratio in diagnosis with US”. Radiology. 161 (2): 443–5. doi:10.1148/radiology.161.2.3532188. PMID 3532188.

[pmid10341686-11] Simonovský V (1999). “The diagnosis of cirrhosis by high resolution ultrasound of the liver surface”. Br J Radiol. 72 (853): 29–34. doi:10.1259/bjr.72.853.10341686. PMID 10341686.

[pmid22144108-12] Trinchet JC, Chaffaut C, Bourcier V, Degos F, Henrion J, Fontaine H, Roulot D, Mallat A, Hillaire S, Cales P, Ollivier I, Vinel JP, Mathurin P, Bronowicki JP, Vilgrain V, N’Kontchou G, Beaugrand M, Chevret S (2011). “Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities”. Hepatology. 54 (6): 1987–97. doi:10.1002/hep.24545. PMID 22144108.

[pmid22424438-13] “EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma”. J. Hepatol. 56 (4): 908–43. 2012. doi:10.1016/j.jhep.2011.12.001. PMID 22424438.

[ProcopetBerzigotti2017-14] Procopet, Bogdan; Berzigotti, Annalisa (2017). “Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy”. Gastroenterology Report. 5 (2): 79–89. doi:10.1093/gastro/gox012. ISSN 2052-0034.

[AagaardJensen1982-15] Aagaard, J; Jensen, LI; Sorensen, TI; Christensen, U; Burcharth, F (1982). “Recanalized umbilical vein in portal hypertension”. American Journal of Roentgenology. 139 (6): 1107–1110. doi:10.2214/ajr.139.6.1107. ISSN 0361-803X.

[ChoPatel1995-16] Cho, K C; Patel, Y D; Wachsberg, R H; Seeff, J (1995). “Varices in portal hypertension: evaluation with CT”. RadioGraphics. 15 (3): 609–622. doi:10.1148/radiographics.15.3.7624566. ISSN 0271-5333.

[BandaliMirakhur2017-17] Bandali, Murad Feroz; Mirakhur, Anirudh; Lee, Edward Wolfgang; Ferris, Mollie Clarke; Sadler, David James; Gray, Robin Ritchie; Wong, Jason Kam (2017). “Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy”. World Journal of Gastroenterology. 23 (10): 1735. doi:10.3748/wjg.v23.i10.1735. ISSN 1007-9327.

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