Evaluation and Management of Suspected Liver Disease

Emergency Room Evaluation

Patients with evidence of coagulation abnormality and any degree of mental alteration without preexisting cirrhosis require immediate emergency room evaluation, as recommended by the American Association for the Study of Liver Diseases 1
Rapid progression with hour-by-hour changes in consciousness may occur, necessitating early transfer to intensive care, according to the American Association for the Study of Liver Diseases 1
Patients with acute liver failure should be referred to a transplant center as quickly as possible for expectant critical care management, as suggested by the American Association for the Study of Liver Diseases 2
Immediate contact with a liver transplant center should be initiated for patients with acute decompensation of established liver disease, as recommended by the American Association for the Study of Liver Diseases 3
Patients with hepatic encephalopathy grade III-IV require ICU admission, unlike those with grades I-II who can typically be managed on a medicine ward, according to the European Association for the Study of the Liver 4

Patients with suspected liver disease but normal mental status and without coagulopathy can be assessed as outpatients, as recommended by the American Association for the Study of Liver Diseases 1
Patients with hepatic encephalopathy grade 0-1 can typically be managed outside the ICU setting, according to the European Association for the Study of the Liver 4
Non-invasive fibrosis tests like FIB-4 and transient elastography can be performed in outpatient settings to assess liver fibrosis, as suggested by the European Association for the Study of the Liver 5 and the International Society on Thrombosis and Haemostasis 6

Immediate measurement of prothrombin time/INR and careful evaluation for subtle alterations in mentation should be performed in the emergency setting, as recommended by the American Association for the Study of Liver Diseases 1
Arterial blood gases, lactate levels, complete blood count, liver enzymes, bilirubin, and ammonia levels should be measured in the emergency setting, according to the American Association for the Study of Liver Diseases 1 and the European Society of Anaesthesiology 7
Hepatic Doppler ultrasound and echocardiography to assess for vascular complications should be performed in the emergency setting, as suggested by the European Society of Anaesthesiology 7
Brain CT imaging to exclude other causes of decreased mental status should be performed in the emergency setting, according to the European Association for the Study of the Liver 4
ALT, AST, and platelet count should be part of routine investigations in primary care for patients with suspected liver disease, as recommended by the European Association for the Study of the Liver 5
Simple non-invasive fibrosis tests such as FIB-4 should be calculated in populations at risk of liver fibrosis, according to the European Association for the Study of the Liver 5
Transient elastography (FibroScan) is preferred to measure liver stiffness in outpatient settings, as suggested by the International Society on Thrombosis and Haemostasis 6

Failing to recognize subtle signs of hepatic encephalopathy, which may indicate need for emergency evaluation, as warned by the American Association for the Study of Liver Diseases 1 and the European Association for the Study of the Liver 4
Relying exclusively on ammonia levels for diagnosis of hepatic encephalopathy, as cautioned by the European Association for the Study of the Liver 4
Not identifying precipitating factors for hepatic encephalopathy, which cause 90% of cases, as emphasized by the European Association for the Study of the Liver 4
Delaying transfer to a transplant center for patients with acute liver failure, as warned by the American Association for the Study of Liver Diseases 1 and 2
Underestimating the severity of liver disease in patients with normal appearing liver enzymes but abnormal synthetic function, as cautioned by the American Association for the Study of Liver Diseases 1