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Ascites Assessment & Chronic Liver Disease Workup
Quynh-Anh Dang • Updated Jun 13, 2021 • 138 hits
An ascites assessment is done during a standard liver disease workup, which involves various physical exams, a detailed medical history, a serological workup, and imaging steps to help guide the final liver diagnosis. Ascites is defined by the accumulation of fluid in the peritoneal cavity, and it can be a sign of an underlying liver condition. In this article, we talk to hepatologist Dr. Parvez Mantry about analyzing ascites for chronic liver disease and hepatocellular carcinoma diagnosis. This is the first installation of a two-part article series on portal hypertension and ascites.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• Ascites assessment begins with taking a detailed medical history, conducting a physical exam, and determining risk factors for chronic liver disease. Ascites is the most common complication of chronic liver disease.
• Further analysis of chronic liver disease progression can be performed by utilizing a liver fibrosis blood test, transient elastography, magnetic resonance (MR) elastography, and liver biopsy.
• When comparing transjugular versus percutaneous liver biopsies, transjugular liver biopsies provide an additional diagnostic benefit of pressure measurements.
• Dr. Mantry does not recommend native liver biopsy in all cases, as it could lead to the unintended consequences or complications. As for targeted liver biopsied for HCC, hepatocellular carcinoma can typically be diagnosed through MRI and CT using criteria such as LiRADS.
Table of Contents
(1) Ascites Assessment & Chronic Liver Disease Workup
(2) Liver Fibrosis Test, Imaging, and Biopsy
(3) The Role of Liver Biopsy in Hepatocellular Carcinoma Diagnosis
Ascites Assessment & Chronic Liver Disease Workup
Dr. Mantry provides background information on his standard chronic liver disease workup, which includes ascites assessment, as well as other aspects of a physical exam, a detailed medical history, and a serological workup. He also explains the link between chronic liver disease and ascites.
[Dr. Christopher Beck]
Can you give us a brief summary of what a good standard chronic liver disease workup looks like?
[Dr. Parvez Mantry]
The first visit for somebody with suspected chronic liver disease is the most important because I want to take a detailed history to get an idea of the chronicity of the illness. I ask for a detailed history of their weight, diabetes, drinking habits, and hemoglobin A1c. Also, it is important to know if they have a strong family history of liver disease because nonalcoholic steatohepatitis can have a genetic predisposition.
Honing into examination features, I check if they have any ascites, sarcopenia, pedal edema, or evidence of encephalopathy. Looking at the basic labs, I can assess the Child-Pugh score and the MELD score. Also, cross-sectional imaging is supremely important. You're a radiologist, so you probably know that very well. I do an ultrasound and, in non-obese patients, a multiphasic MRI to assess their vasculature and their liver surface to rule out cancers.
Also, the serological workup is extremely important. When we start from fresh, we never assume anything. If they're a Baby Boomer, I will double check that their hepatitis panel has been checked because they could still have hepatitis C, even if they present with no risk factors. Then, we check the autoimmune markers with muscle antibody and antinuclear antibody. If they are younger and if nothing else is evident, I will check their cellular plasma and alpha-1 antitrypsin. I will also check their iron studies and any other genetic markers to see if they have any genetic condition predisposing to cirrhosis.
[Dr. Christopher Beck]
Can you give us a brief overview of how ascites is related to chronic liver disease?
[Dr. Parvez Mantry]
When we look at the complications of chronic liver disease, we divide it into two areas. One area is complications related to liver synthetic dysfunction because the liver is responsible for production of proteins, chemicals, and clotting factors. The second area is complications related to portal hypertension. When the liver architecture is lost, it loses its ability to filter blood. The unfiltered blood backtracks into veins, which surround the stomach, esophagus, and spleen. This leads to varices, because the blood is trying to find a way to get back into the systemic circulation through the collaterals. Those are the two main ways we decipher the complications from liver disease.
Ascites, which is the most ominous and the most common complication of chronic liver disease, needs a component of both.
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Liver Fibrosis Test, Imaging, and Biopsy
Ascites assessment can involve a further liver fibrosis test or imaging that shows liver surface abnormalities. Dr. Mantry highlights four different methods to analyze the degree of fibrosis: the FibroSure liver fibrosis test, FibroScan (also called transient elastography), MR elastography, and liver biopsy. Each method has its own advantages and limitations, so it is important to assess the appropriateness and availability of each type for each patient. He also discusses the value of liver biopsies and his preference between percutaneous and transjugular biopsies.
[Dr. Christopher Beck]
At what point does a native liver biopsy come into the chronic liver disease workup? Is that something that all patients with chronic liver disease will go through, or is it performed on a case by case basis?
[Dr. Parvez Mantry]
That's a great question. For example, let’s say that I have a patient coming to me for evaluation of abnormal liver function tests. They had an ultrasound which shows a core psychogenic liver or a different echogenicity. In those patients, it is really important to assess their liver fibrosis, and we do it by one of four methods.
One is a liver fibrosis blood test, called FibroSure, which is the least reliable, but it is readily available.
Two, a FibroScan, also called transient elastography, which we use most commonly. It will give a liver fibrosis score from 0 to 4 (0 being normal and 4 being cirrhosis).
Three, we now have the ability for MR elastography, which we had acquired at our center seven years ago. It's a really neat non-invasive tool that can tell us exactly how much damage the liver has.
Four, the last but not the least important, is the liver biopsy, which a lot of us perform ourselves. It's a 10 minute procedure, but it is slightly invasive. We give a patient some sedation and pick a spot. This ultrasound-guided between the intercostal spaces and we use a 16 gauge needle to take a sample. That is still considered the gold standard for diagnosis of a chronic liver disease, especially in conditions like steatohepatitis, if we know that the patient does not already have full-fledged cirrhosis.
[Dr. Christopher Beck]
How often do patients get referred for a transjugular liver biopsy instead of a percutaneous liver biopsy?
[Dr. Parvez Mantry]
There are a few conditions or situations where I would prefer a transjugular liver biopsy. Oftentimes, we will have a patient who does not have any obvious features of liver disease, and yet shows variceal bleeding or ascites. I look at the liver numbers, and they're all completely normal. Of all the risk factors I pointed out, the patient does not seem to have any. All the serological workup is negative. The ultrasound or CT or MRI shows a very smooth liver. I want to find out: What's wrong with the liver? Alternatively, are the ascites and bleeding coming from a different issue, like a vascular issue or an issue that is non-related to the liver?
In those cases, I will always perform a transjugular biopsy because my radiologists can tell me the hepatic venous wedge gradient, which is an indirect measurement of the portal vein pressure. If it is more than 12, I know that this patient has portal hypertension and is most likely cirrhotic. Of course, a biopsy will corroborate as well. If pressure is low, then I know that this patient has extrahepatic portal hypertension or something else causing the ascites and bleeding.
The Role of Liver Biopsy in Hepatocellular Carcinoma Diagnosis
While liver biopsy can be extremely helpful as a diagnostic tool, there are circumstances where biopsy is not ideal. Dr. Mantry warns that hepatocellular cancer tract seeding or hemorrhage can result from liver biopsy, and it is safer to reach a hepatocellular cancer diagnosis through other means.
[Dr. Christopher Beck]
Is hepatocellular carcinoma considered one of the complications of chronic liver disease?
[Dr. Parvez Mantry]
Hepatocellular carcinoma is a very important complication of cirrhosis. It is directly tied to development of cirrhosis, and 9 out of 10 people presenting with liver cancer in the United States will have underlying cirrhosis. That's primarily linked to faulty regeneration in the liver because when the liver gets really badly damaged, it tries to regenerate. However, when the regeneration is defective, it causes dysplasia and predisposes to cancer.
[Dr. Christopher Beck]
I'm interested to know if liver biopsy plays a role in hepatocellular carcinoma diagnosis at your institution.
[Dr. Parvez Mantry]
That's a great question. Biopsy is not required for hepatocellular carcinoma diagnosis. It is actually an imaging diagnosis. In fact, we discourage biopsy for a majority of the time for two reasons. One, this is a very vascular tumor and by biopsying, you can spread it by intraperitoneal spread through bleeding. Two, there is a high false negative rate. 95 to 98% of the time, multiphasic MRI, with all its sequences and restricted diffusion imaging, can diagnose an hepatocellular carcinoma. If the patient is not a good candidate for an MRI (for example, if there was an MRI-unfriendly pacemaker or they are severely claustrophobic) then we employ a quadruple-phase CT. Between the two, we can diagnose hepatocellular cancer about 98% of the time.
Podcast Contributors
Dr. Parvez Mantry
Dr. Parvez Mantry is the Medical Director of the Liver Institute Research and the Hepatobiliary Tumor Program at the Methodist Health System in Dallas, Texas.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, May 17). Ep. 127 – Portal Hypertension and Ascites Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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