Cirrhosis. Finally. Take your liver game to the next level with tips from @liverprof, Scott Matherly MD, Assistant Professor of Medicine at Virginia Commonwealth University. Topics include: exam findings in cirrhosis, interpreting liver function tests, incidental cirrhosis on imaging, fatty liver disease, steatohepatitis, hep c, shear wave elastography, screening for varices and hepatocellular carcinoma, pathophysiology, and lifestyle measures for initial management. This episode is sponsored for CME-MOC credit by the American College of Physicians. ACP members can claim free credit at acponline.org/curbsiders (goes live at 9am on release date).
Credits: Written by: Cyrus Askin MD CME questions by: Cyrus Askin MD Produced by: Cyrus Askin MD and Matthew Watto MD Hosts: Cyrus Askin MD, Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Scott Matherly MD
Shear wave elastography: Can effectively diagnosis cirrhosis in thin patients with hepatitis C. More useful for negative predictive value in obese patients with diabetes and/or fatty liver disease (i.e. a negative test is reassuring, but an intermediate or high risk test needs liver biopsy to confirm). –Dr Matherly
Red flags on lab testing: Low albumin, low platelets, and/or prolonged INR. –Dr Matherly
Screen for varices in cirrhosis at the time of diagnosis. Subsequent testing every 1-3 years based on size. -Dr Matherly
Screen for hepatocellular carcinomawith hepatic ultrasound every 6 months after a diagnosis of cirrhosis. Alpha fetoprotein was removed from the guidelines, but some experts still use it to augment screening. -Dr Matherly
Diet:High protein diet (at least 1 gm/kg body weight/day) is recommended due to cirrhosis being a catabolic state. Low sodium diet is not useful for cirrhotics unless ascites is present. -Dr Matherly
Normal ALT – most lab values are NOT evidence based 8
Female: 19-25 IU/L
Male: 29-33 IU/L
Thrombocytopenia: an immediate red flag when evaluating a patient for liver disease (<150×109) 9
This may indicate advanced disease as the thrombocytopenia is often due to portal hypertension, which develops in the setting of cirrhosis and leads to splenic sequestration of platelets/ hypersplenism
Albumin: hypoalbuminemia due to liver disease suggests advanced liver disease 10
PT/INR: One of the most sensitive markers for hepatic function, elongated INR suggests advanced liver disease, readily available virtually anywhere 11
FIB-4: First developed for estimating degree of fibrosis in HIV/HCV co-infection; later found to be more generalizable. Useful when imaging is not already available, to screen patients when there is concern for cirrhosis 12
<1.45 has NPV of 90% for advanced fibrosis (sens. 81%)
>3.25 has PPV of 65% for advanced fibrosis (sens. 97%)
Fib4, and other non-invasive tests, are “good at the margins” – indeterminate scores need to be invasively evaluated – Dr. Matherly
Don’t forget hepatitis C testing!
HCV: If born 1945-1965, CDC recommends Hep C testing 13
Risk of liver cancer in a cirrhotic is anywhere from 3-5% per year
Ultrasound surveillance every 6 months following initial diagnosis
Disclosures: Dr. Matherly reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
01:19 Intro to the show and our guest
04:15 Guest one liner, books recommendations, and career advice
09:04 Cyrus’ pick of the week
10:14 Clinical case of abnormal liver functions tests
11:12 Seven hand findings of cirrhosis
13:28 Should we screen for NASH?
15:28 Incidental finding of cirrhosis on imaging
17:47 Next steps after diagnosis of cirrhosis
20:36 Non-invasive scoring systems to predict cirrhosis
23:55 Liver biopsy
25:33 Shear wave elastography
29:10 Recap of what we learned so far
31:58 Three ways cirrhosis can kill you
33:56 Counseling patients about cirrhosis
36:05 Management of NASH and early cirrhosis
42:55 Screening for varices and hepatocellular carcinoma
Goal: Listeners will know the basics regarding pathophysiology in cirrhotic patients, know how to approach a patient with elevated liver-associated enzymes when cirrhosis is on the differential and know about scoring systems / tests to identify / grade cirrhosis. Importantly, they will know what evidence-based interventions they can make at the primary care level which may improve morbidity and mortality. They will know the complications of cirrhosis and how to screen for them based on the most recent evidence.
After listening to this episode listeners will…
Understand the pathophysiology of cirrhosis, specifically the process through which fatty-infiltration develops into fibrosis and ultimately into the disease known as cirrhosis
Be able to identify the common causes for cirrhosis: HBV, HCV, Alcoholism, non-alcoholic steatohepatitis
Know what primary care interventions can be made to help prevent the development of cirrhosis
Know who to screen and how to screen for cirrhosis in asymptomatic patients with risk factors
Know the appropriate work up for a patient who presents with elevated liver-associated enzymes when there is concern for cirrhosis
Recall the tools/labs/studies are available for evaluating a patient when concerned for cirrhosis
Be comfortable with evidence-based interventions the primary care provider may use to treat the cirrhotic patient
Know the complications associated with cirrhosis, how/when to screen for them and the basics regarding their management
When to refer to a hepatologist and what role do hepatologists play in the outpatient management of a cirrhotic patient
Garcia-tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310-335.
Great episode. HAPPY 100th EPISODE! (though I am a little disappointed that you're pulling a Harry Potter/Hunger Games and splitting it into two parts. Error on the Fib-4 score. It should read (Age*AST)/(platelets*√ALT)
I feel like it was suggested in the podcast that if shear wave elastography was not negative that the next step would be to proceed to liver biopsy. Is that always necessary? I feel like that would produce a lot of liver biopsies in a lot of fatty liver patients with a lot of negative results. Any guidance?
Dr Matherly suggested that shear wave elastography is reliable in thin patients with hepatitis C and has largely replaced liver biopsy in this cohort. In patients with fatty liver disease a low risk result is reassuring (and requires no further testing), but an intermediate or high risk result often necessitates a liver biopsy to determine whether or not cirrhosis is present. I hope this helps.
Thank you . It was a great episode!