Improving cirrhosis detection, outcomes
One of the biggest gaps in cirrhosis management is identifying patients and getting them into subspecialty care.
The last three decades have seen a sharp increase in the number of cirrhosis deaths in the United States, with figures reported by The Lancet Public Health in August 2024 showing an uptick of 87% between 1990 and 2019.
Primary care physicians can help reduce the national burden of the disease and chip away at rising numbers, according to experts, by recognizing risk factors early to expedite interventions and working with subspecialists to better comanage patients and improve outcomes.
Individuals with any of the three main causes of cirrhosis (metabolic dysfunction-associated steatotic liver disease [MASLD], hepatitis C, and alcohol use) “comprise about 80% of patients who are actually waiting for a liver transplant,” explained ACP Member Dushyant Singh Dahiya, MD, a gastroenterology, hepatology, and motility fellow at the University of Kansas School of Medicine in Kansas City.
However, disparities exist in who is most affected by cirrhosis. The Lancet Public Health study found that rates are highest in the South, including in Texas and New Mexico, said lead author Hasan Nassereldine, MD, a postdoctoral scholar at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle. The data also showed that “in 2019, cirrhosis mortality rates were highest among American Indian and Alaskan Natives, followed by the Latino population and the White and Black populations [respectively]. It was lowest in the Asian [population],” he said.
Underlying causes of cirrhosis also vary across populations.
“If you're talking about White Americans, alcoholic liver disease is the most common cause of liver cirrhosis. If you talk about Japanese, American Native, Hawaiians, and Hispanics, MASLD is the most common cause. But if you're talking about Black Americans, hepatitis C is the most common cause,” explained Dr. Dahiya, who was not involved in The Lancet Public Health research.
“Traditionally, cirrhosis has tended to affect individuals who are not diagnosed on time, meaning individuals who do not have access to health care, or individuals who are on the lower subset of the population in terms of incomes,” he said.
Knowing which populations are most affected is crucial for primary care physicians, who play an instrumental role in screening for cirrhosis and its risk factors. Notably, one of the biggest gaps in cirrhosis management is identifying patients and getting them into subspecialty care, said Mary Thomson, MD, MSc, assistant professor of medicine in the division of gastroenterology, hepatology, and nutrition at the University of Minnesota in Minneapolis.
Primary care is the first point of contact for these patients, explained Dr. Dahiya. “No patient is going to directly go to a hepatologist and be like, ‘Hey, can you check me for liver cirrhosis?’ … [Primary care physicians] are very, very critical in determining how a patient should be screened or when a patient should be screened.” (For more on talking to patients about liver findings from the subspecialist perspective, see Pearls from I.M. Peers.)
Suspecting cirrhosis
Experts agreed decompensated cirrhosis is easier to diagnose than compensated cirrhosis, as patients will present with telltale signs like jaundice, confusion, and memory problems. For compensated cirrhosis, a thorough history and physical can help. Any patient with risk factors, including high body mass index (BMI), diabetes, obesity, alcohol use disorder, signs of liver dysfunction, or MASLD, should be evaluated for cirrhosis, experts said.
Patients with compensated cirrhosis may exhibit symptoms like fatigue and weight loss, but these patients can be asymptomatic too, Dr. Dahiya said. In patients where compensated cirrhosis is less obvious, subtle lab findings can hold clues, explained Eric S. Orman, MD, MSCR, a hepatologist and associate professor of medicine at Indiana University School of Medicine in Indianapolis. “Thrombocytopenia … should clue providers into cirrhosis,” he said. Low albumin levels or elevation in alanine aminotransferase and aspartate aminotransferase levels should also trigger suspicion, Dr. Dahiya added.
Some asymptomatic patients are also identified via unrelated imaging. “We're actually seeing an uptick in those cases where you're doing imaging for a completely different reason, and you're finding that these patients [have] liver cirrhosis although they're completely asymptomatic,” Dr. Dahiya said.
Tips for management
The main goal in compensated cirrhosis management is to prevent complications and progression to decompensation. But how that's achieved depends on the underlying issue. “There's not a generic approach that we would take for cirrhosis of any cause,” said Dr. Orman. If a patient has a high BMI, you should encourage them to lose weight; if they are still using alcohol, you should encourage them to stop; if they have hepatitis, you should treat it, and so on, explained Dr. Nassereldine.
Lifestyle modifications are important for all patients with cirrhosis, but especially those whose disease stems from MASLD, a condition that has increased alongside the rise in obesity. One study published by Clinical and Molecular Hepatology in August 2024 found that 38% of adults worldwide currently have MASLD, a total projected to increase to over 55% by 2040.
Improving diet and exercise can be done with the help of dieticians. “A multidisciplinary approach is always key, so involving [dieticians] early” is helpful, Dr. Dahiya said. This can be done via telehealth for patients who are in underserved areas or aren't able to travel. Because this is such a crucial component of care, he also recommends primary care physicians schedule separate appointments to go over comprehensive lifestyle guidance with patients who have cirrhosis and not try to squeeze the subject into an already cramped 15- or 30-minute appointment.
In a review published by the Cleveland Clinic Journal of Medicine in November 2023, Dr. Dahiya and colleagues outlined lifestyle recommendations for patients with cirrhosis and specific complications. For example, “for patients with liver cirrhosis and ascites, sodium restriction is a mainstay in managing symptoms. Sodium intake should be limited to less than 2 g/day or 88 mmol/day, as it has been noted that the development of ascites is secondary to renal retention of sodium,” they wrote.
When it comes to alcohol intake, “people who have cirrhosis, from any reason, shouldn't be drinking any alcohol at all,” said Dr. Thomson. “Having regular conversations with patients about their alcohol use and knowing when people need to be counseled on abstaining completely is important.”
A team approach is also crucial here, explained Dr. Orman. Involving a psychiatrist or referring patients to social work can go a long way in linking patients “to resources like cognitive behavioral therapy and other therapies that can help them reduce alcohol intake,” he said.
Putting alcohol use on everyone's radar is especially important now, as research shows that increased consumption during the COVID-19 pandemic continued through 2022. A cross-sectional study published by Annals of Internal Medicine in November 2024 found that compared with 2018, there were absolute increases in any alcohol use and in heavy alcohol use among Americans both in 2020 and 2022.
“There's a lot more alcohol-related liver disease out there now than there ever was, including a lot of young people” in their 30s and 40s, said Dr. Thomson, who was not involved in the study. “We've just seen so many people drinking a lot more now than they ever have been.”
In addition to talking with patients about alcohol, physicians can also work one-on-one to eliminate stigma associated with cirrhosis, especially in ethnic minorities, said Dr. Dahiya. “A lot of people are not just able to accept that ‘I have liver cirrhosis' or ‘I need a liver transplant.’ So … telling them that ‘This is a condition that we deal with all the time. There's nothing new about it. It's like any other disease’” can help, he said.
More education about disparities in cirrhosis rates could also boost identification of these patients by prompting physicians to keep an eye out for the condition in certain populations, Dr. Dahiya added.
On a systemic level, raising awareness increases the possibility for targeted interventions, whether that's free clinic days to help marginalized communities or other initiatives tailored to at-risk populations, explained Dr. Nassereldine. “The main initiative for cirrhosis specifically, since it's a preventative disease, is to prevent the occurrence,” he said.
Referral and comanagement
Ideally, all patients diagnosed with cirrhosis should be referred early to subspecialty care, and primary care physicians should not wait until a complication arises to do so, experts stressed.
“We want to see them early on, so we can actually start [the liver transplant process] from the get-go, if the patient qualifies,” said Dr. Dahiya. “We're easing the process down the line. We don't want to be seeing these patients directly in the ICU.”
Dr. Thomson agreed. “There's a huge gap in liver transplant care that just comes with people having never been referred for a liver transplant,” she said.
Early referral can also help prevent and address common complications like ascites, esophageal varices, spontaneous bacterial peritonitis, and hepatic encephalopathy, to name a few.
Although experts agreed these should all be handled by subspecialists, financial hurdles and geographic constraints may make that difficult.
“In people who have compensated cirrhosis—meaning that they have cirrhosis, they don't have ascites, they don't have confusion from liver disease, their labs are pretty normal, their [Model for End-stage Liver Disease score] is low—those people probably could be managed by primary care alone, particularly if there's not a lot of resources to gastroenterology care,” explained Dr. Thomson.
In the absence of subspecialist services, primary care physicians should be sure to screen patients with cirrhosis for hepatocellular carcinoma every six months, she said.
“That's kind of a simple thing that primary care doctors can help with while [patients are] waiting to be seen,” said Dr. Thomson. “People who have cirrhosis, even if they're otherwise compensated and feeling well, they still should be undergoing liver cancer screening with at least an ultrasound” twice a year.
Any additional procedures, such as an endoscopy for screening for esophageal varices, are “all best done under the guidance of a gastroenterologist or hepatologist,” said Dr. Orman.
Handling hospitalizations
Readmission rates are high among patients with cirrhosis, and most readmissions are not preventable, according to research Dr. Orman and colleagues published in the American Journal of Gastroenterology in February 2024.
The analysis of 654 cirrhosis patients at a single center found 246 (38%) readmissions, and of these, just 29 (12%) were judged preventable. The findings underscore the importance of preventing hospitalizations in the first place, a goal aided by early detection and close monitoring for complications.
As one example, Dr. Dahiya explained how patients with cirrhosis should undergo an upper endoscopy as early as possible to assess for varices and to determine if beta-blockers are needed in order to prevent hospitalization.
“Or if a patient has abdominal distension, we want these patients to be on diuretics. So we're preventing a hospitalization where they go into volume overload or they go into respiratory distress,” he said.
He proposed one possible method to optimize monitoring, where hepatologists and primary care physicians alternate seeing the patient every three months. “In a year, the patient is getting four appointments, but we are dividing the work between the primary care doctor and the hepatologist,” he explained. “We are preventing hospitalizations because the patient is just being seen so often, and they're being assessed so often, that we're taking care of any issue before it even arises.”
If a patient does end up being hospitalized, a robust transitional care plan needs to be put in place for discharge and follow-up, Dr. Orman said.
“We aim to see them within the first one to two weeks whenever possible, to make sure that any changes that were made during their hospitalization are working well for them and that we don't see any early signs that they're going to need readmission,” he said.
Patients hospitalized for hepatic encephalopathy specifically should avoid medications or substances that might make them confused, along with any other sedating medications, Dr. Thomson said, noting that rifaximin has been shown to reduce readmissions for this complication. However, she explained, “Sometimes people, despite being prescribed [rifaximin], they don't have access to it because it's too expensive, so see what options are available in terms of patient assistance.”
Postdischarge follow-up can be with a primary care physician or a subspecialist.
“The more follow-up the better,” said Dr. Orman. “As hepatologists, we are very focused on just the cirrhosis, and there may be other aspects to their care that we are not necessarily managing, that are probably best left for primary care to make sure that those are getting addressed.”
Dr. Dahiya agreed that working together is paramount.
“Everybody is very busy. … so sometimes things can fall through the cracks,” he said. “Coordination between primary care physicians and specialists, per se, I think would go a really, really long way in ensuring that the patients are getting what they need.”
