Authors: Ken Flora, M.D., gastroenterologist; Jeremy Holden, M.D., gastroenterologist; Josh Nicholson, PA-C
Being able to assess the level of fibrosis and make appropriate referrals is important in the care of patients with steatotic liver disease (formerly known as fatty liver). While remaining on a spectrum in severity, with the majority having no inflammation or scar (F0-steatosis) and some progressing to cirrhosis (F4-NASH), we know that liver-related complications can develop at intermediate stages (F>2). The ability to stage fibrosis without liver biopsy has made identifying and triaging those at risk for progression easier.
In 2023, the American Association for the Study of Liver Diseases published a guidance with an assessment and referral algorithm for fatty liver1. The goal is to exclude “advanced” fibrosis to reassure patients and avoid unnecessary GI or hepatology referrals. The main feature is the use of the FIB-4 score and determining if it is less than 1.3 or greater than 2.67. FIB-4 is found online and is included in most smartphone medical apps. It is a simple calculation based on age, AST, ALT and platelet levels. A score of <1.3 is reassuring and referral is not needed, while a score of >2.67 suggests a higher fibrosis level and referral to GI/hepatology should be considered.
The FIB-4 has an ‘indeterminant zone’ between 1.3 and 2.67 in which advanced fibrosis is neither ruled out nor confirmed. Patients within this range should undergo additional risk assessment with the Enhanced Liver Fibrosis (ELF) Test (Labcorp). ELF is a proprietary serum test available in most labs. A score <9.8 suggests low risk for progression to advanced fibrosis and scores >9.8 suggest higher risk and referral should again be considered.
Ultrasound-derived Elastography (Gateway Medical Office Building), RAYUS Imaging), FibroScan (Mount Hood MC, OHSU, Kaiser, VA, TOC GI-West) and MR elastography (MRE) are the highest level of ‘noninvasive’ testing and are available at facilities throughout Portland, though MRE is currently cost prohibitive. These can all be ordered by either primary or specialty providers. They all use vibration on a physical or molecular level to stage liver scar with relatively similar levels of accuracy. These should be considered in patients with FIB-4 scores >1.3.
Regardless of hepatic fibrosis stage, patients with metabolic syndrome will continue to need aggressive management as, for now, that remains the primary preventive treatment for steatotic liver disease and cardiovascular complications remain the most frequent cause of morbidity and mortality in this group of vulnerable patients.
Fatty infiltration of the liver is increasingly common. However, most patients are at low risk for developing advanced liver fibrosis. Risk stratification is easily done in the primary care clinic and can result in peace of mind and prevent unnecessary specialist referrals.
To make a referral:
The Oregon Clinic-Gastroenterology East at Gateway
1111 Northeast 99th Avenue, Suite 301
Portland, OR 97220
503-963-2707
1AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77:1797
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