Assessing, reassuring patients with potential liver disease

Oftentimes patients are referred to me as a hepatology expert and they're already very worried because another physician has told them that they're going to die of liver disease. But it's usually not that dire.

Most of these patients find out that they have issues with their liver, in particular hepatic steatosis, when they are presenting to their primary care physician or an ER with unrelated symptoms. Maybe they've had severe abdominal pain or some other vague symptom, and it prompts imaging of their abdomen. No one's really thinking at the time that they're going to see hepatic steatosis, right? They're looking for something acute and then, incidentally, they find something else that would often prompt a referral. The other really common scenario is that people will have very elevated liver enzymes, and sometimes the level of elevation makes referring clinicians think that they have very severe liver disease.

Patients do come in very, very worried. When they enter my office, I start with just a general question, “How are you doing?” I try to get a sense of their mood by their expressions. If they're looking worried, I say, “You look nervous. What are you worried about the most?” My typical question after that is, “Do you understand why you were referred to see me today?” or “What is your understanding of why you are here today?” Sometimes people have a fairly good sense. Oftentimes they don't. We just start with answering that question about why someone was concerned and how they ended up needing to see me in the hepatology clinic. Between those two questions, it oftentimes will relax people.

If they tell me at the outset that they are worried that someone told them they have the most severe form of liver disease, or that they are going to die or they need a transplant immediately … I will have reviewed their medical records, and I will go ahead and answer their most concerning question up-front, so that then they have time and space to listen to everything else that I have to say.

Most of the time the news is that their liver disease is not very advanced. I see patients who have metabolic dysfunction-associated steatotic liver disease (MASLD, formerly known as nonalcoholic fatty liver disease). Typically, my patients are not suffering with symptomatic liver disease. At that stage, most liver disease is very reversible, and so I start with that information. They take a sigh of relief, and then we can get on to the rest of the history taking.

I take a general history, as I think probably all internists do, but with a focus on the issues that I think are most relevant to liver disease and liver health. When I get to questions about alcohol, I normalize them. I ask every single patient who comes into my clinic about their alcohol intake, because in this way, I feel I limit my own bias, so I don't decide who I need to ask that question of and who I don't need to ask that question of. Just as I ask every patient about their dietary patterns and their weight trajectory over time, alcohol is a normal question.

I use the AUDIT-C template to get information about alcohol intake, but I don't just ask static questions. I first ask patients an open question, “Do you drink alcohol?” Usually, people will say either yes, no, or occasionally. Occasionally is a very common answer, and that has a lot of different meanings for people. Then I'll ask them to describe what their typical alcohol intake is, and I'll dive down from there. If their description doesn't tell me how often they're drinking or what they're drinking, I'll ask those questions more specifically. I certainly will always ask about binge patterns of drinking, because that pattern is the most deleterious pattern of alcohol intake.

I also will ask questions about consequences of alcohol if I get the sense that they do have at least a moderate level of alcohol intake. I will add on questions: “Have you ever had a DUI? Has anyone ever told you that they were concerned about your drinking? Have you been concerned about how much you drink? Have you had any employment issues because of drinking?” That really gives me a sense of the magnitude of their alcohol intake, and then I move on to the rest of the questions and physical exam.

During my wrap-up, when I'm talking about alcohol, I talk about it in the way that experts like myself in metabolism would talk about anything that impairs metabolism, because alcohol is a systemic toxin and it has a myriad of metabolic effects. I don't talk about it in behavioral terms. I talk about it in metabolic terms, and particularly how alcohol affects the metabolism of the liver. I'll explain why alcohol causes extra fat in the liver, and I let them know that alcohol prevents the liver from breaking down fat, from burning the extra fat. I liken it to a car, the fuel and the engine.

Patients usually can relate to that analogy very well. Once I explain that this is all reversible by reducing alcohol intake with the goal of quitting alcohol, they really do, for the most part, seem to be very accepting of that recommendation. I don't usually get the sense that people are feeling attacked or blamed. I really just try to meet people where they are in terms of what they understand about the effects of alcohol.

When I see patients come in with suspicion of a high likelihood of fibrosis, but I'm looking at the full clinical picture and nothing else is really pointing in that direction, then I can readily assure people that I'm not very worried about them having very advanced liver disease. It doesn't mean they don't have liver disease or that we don't need to be very aggressive. I actually practice very aggressive hepatology with all of my patients, no matter the stage of disease, because I'm a believer in preventing advanced liver disease, not just watching and waiting until it develops. But that being said, patients are very reassured when they know that there's interventions that can fully reverse the findings.