Cirrhosis — Assessment & Labs

The liver fails silently for years — by the time you see jaundice and ascites, 80% of hepatocytes are already gone. Knowing which labs shift first changes everything.

Cirrhosis is irreversible scarring that replaces functional hepatocytes with fibrotic tissue, progressively destroying the liver's synthetic, metabolic, and detoxification capacity. Assessment focuses on two domains: physical findings and laboratory markers of liver function. Physical findings progress from subtle to obvious — early signs include fatigue, anorexia, and right upper quadrant dull aching; later signs include jaundice, ascites, spider angiomata, palmar erythema, caput medusae, and gynecomastia in males. Lab interpretation is where NCLEX questions live. The liver makes albumin and clotting factors, so expect decreased albumin (normal 3.5–5.0 g/dL) and prolonged PT/INR. Bilirubin rises (normal total 0.1–1.2 mg/dL) because the damaged liver can't conjugate or excrete it — producing jaundice when levels exceed approximately 2.5 mg/dL. AST and ALT elevate with hepatocyte destruction but may paradoxically normalize in end-stage cirrhosis when few hepatocytes remain to release enzymes. Ammonia rises because the failing liver can't convert it to urea, but ammonia monitoring and management belong to the hepatic encephalopathy sibling. Thrombocytopenia occurs from splenic sequestration due to portal hypertension. Always assess for bleeding tendencies — check gums, stool, and bruising.

Key Distinctions

Don't confuse elevated AST/ALT (hepatocyte damage markers) with albumin and PT/INR (synthetic function markers) — synthetic markers tell you how well the liver is actually working, while enzymes only tell you cells are dying. Students often think normalizing AST/ALT in cirrhosis means improvement; it can actually mean fewer living cells remain to release enzymes. Jaundice becomes visible at bilirubin around 2.5 mg/dL, not at the upper limit of normal.

Clinical Pearl

Enzymes tell you cells are dying; albumin and PT tell you the liver has stopped working. When enzymes drop but albumin and PT worsen — that's end-stage, not recovery.