When to Refer a Patient with Liver Disease

Chronic liver disease is a major problem in the United States with over 4 million people infected with Hepatitis C alone. Many of these patients show no signs or symptoms of disease. When patients become symptomatic it is often too late for treatment and these patients may require liver transplant evaluation. Patients with any of the following should be screened for chronic liver disease:

• A history of blood transfusion prior to 1992
• Previous use of injection drugs or intranasal cocaine
• Multiple sexual partners
• Birth or parental birth in Asia, Africa, Eastern Europe or the Mediterranean
• History of arthritis or abnormal liver tests
• Family history of liver disease

All patients should be screened for excessive alcohol use with a CAGE questioner. By judicious screening of a healthy population, much liver disease can be discovered in the presymptomatic stages and treatments can be offered for viral hepatitis, alcoholic liver disease, early cirrhosis, and autoimmune and inherited forms of liver disease.

When patients become symptomatic from chronic liver disease with the development of jaundice, ascites, encephalopathy, muscle wasting, gastrointestinal bleeding or coagulopathy, they need to be referred to a liver transplant center regardless of their age or etiology of liver disease. Many of these patients could be candidates for liver transplantation which is a life-saving procedure.

Most patients with symptomatic liver disease will not live three years, and half of those with severe symptoms will not live six months without a liver transplant. With proper management, the majority (over 80 percent) of those selected for the Liver Transplant List will survive to receive a transplant. Of these, 90 percent will survive one year after the transplant, and 80 percent will survive five years after liver transplant with excellent quality of life.

One of the most dreaded complications of chronic liver disease is the development of Hepatocellular carcinoma. Currently, all patients with cirrhosis should be screened at least every six months with Alpha-Fetoprotein and ultrasound to detect early Hepatocellular carcinomas. Small cancers can be resected from noncirrhotic livers, while tumors in cirrhotic livers will usually be managed with liver transplantation. All patients with liver cancer should be referred to a transplant center where optimal management strategies are available.

Patients with the Following Conditions Should be Referred to Hepatology

• Hepatitis C
• Active hepatitis B (Hepatitis B surface antigen positive)
• Symptomatic liver disease (ascites, jaundice, muscle wasting, severe fatigue, etc.)
• Elevated alfa-fetoprotein
• Liver masses seen on ultrasound, CT or MRI
• Abnormal liver tests and inflammatory bowel disease
• Cirrhosis of the liver, if the patient wants to be considered for liver transplantation
• Chronic liver disease such as primary sclerosing cholangitis and primary biliary cirrhosis
• Autoimmune hepatitis
• Benign and malignant strictures of the bile ducts
• Non-alcoholic fatty liver (NAFL or NASH)

Patients with the Following Should be Referred for Transplant Consideration

• Symptomatic liver disease
• Abstinent alcoholic liver disease with cirrhosis
• Viral hepatitis with cirrhosis
• Cirrhosis with liver mass on imaging study
• Cirrhosis with acute or chronic gastrointestinal bleeding
• Ascites that does not respond to diuretics
• Patients with liver disease and encephalopathy
• Budd-Chiari Syndrome
• Metabolic diseases such as hemochromatosis, Wilsons disease, primary oxalosis, alfa-1 anti-trypsin deficiency, glycogen storage disease
• Symptomatic polycystic liver disease