The vision of the American Association for the Study of Liver Diseases (AASLD) is to prevent and cure liver disease. According to the Centre of Disease Control data of over 2 decades, the number of deaths in men has increased by 2-fold and it is even worse for women. Liver cancer, viral hepatitis, alcohol associated liver disease, and Metabolic dysfunction-associated steatotic liver disease (MASLD) are the main causes, except hepatitis. A latest workforce study on the experts who can manage liver disease has shown a significant deficit in the number of hepatologist needed to deal with the liver disease by 2033. To prevent and cure liver disease, vaccinations, screening patients, antiviral therapy can be applied. Lifestyle changes and liver directed therapies can help in alcohol associated liver damage and MASLD.
The natural history of liver disease ranges from liver fibrosis F0/1, F2, F3 1 to cirrhosis, decompensation and portal hypertension (06:19) or as liver stiffness as 5, 10 and, 15 kPa. Screening and stratification in the early stages and managing the underlying liver disease helps in the management of underlying liver disease. In patients with cirrhosis, screening for portal hypertension, liver cancer surveillance, symptom management and eventually liver transplant should be practiced. Carvedilol helps to decrease or slow the progression of compensated/chronic liver disease and it improves survival by a few months. However, it is not creating a significant and impact and the management has to go upstream through early diagnosis and early treatment (prevention). Preventive medicine has number of stages Primary prevention is preventing disease process. Secondary prevention is preventing illness, which may include early diagnosis and treatment. Tertiary prevention is preventing complications once an illness has occurred. In liver disease for viral hepatitis, primary prevention would be universal vaccination, secondary prevention would be detecting undiagnosed viral hepatitis B and C, and then applying antiviral treatment. For alcoholic liver disease (ALD), avoid using heavy alcohol, for MASLD, preventing obesity, Type two diabetes and metabolic risk factors. Secondary prevention would be screening for liver fibrosis, managing Alcohol Use Disorder and managing metabolic syndrome obesity with liver directed therapy. However, once cirrhosis has occurred, beta blockers need to be prescribed along with hepatocellular carcinoma (HCC) surveillance, variceal ligation if appropriate, transjugular intrahepatic portosystemic shunt (TIPS) and transplant. For HCC preventing chronic liver disease would be primary prevention, surveillance and when the cancer occurs, multidisciplinary intervention is secondary and recurrence prevention would be tertiary. There may be shared responsibilities in the middle depending on available expertise. Preventive hepatology includes screening and treating viral hepatitis, screen and manage the risk factors for MASLD and liver directed therapy, for HCC, preventing chronic liver disease and doing surveillance.
The core skill sets for preventive hepatology includes fibrosis assessment to really identify people at risk of cirrhosis, obesity medicine, addiction medicine, vital hepatitis screening and treatment and surveillance. It acts as a nerve centre that has multidisciplinary capability and connects with other specialties when skill sets need referral and help. This includes transplant, hepatology, obesity, medicine, preventive cardiology, psych/social services and endocrinology. There is a need for early detection of liver fibrosis to prevent liver complications. The all-cause mortality and liver-related mortality accelerates as the fibrosis progresses and the inflection point is around F2 fibrosis stage.
The steatosis-associate fibrosis estimator (SAFE) score is a non-invasive test to detect stage two fibrosis. All the other non-invasive tests are calibrated to look for F3 plus fibrosis. This was published last year for Primary Care Decision-Making Potential Intervention. It is a logistic model which has been demonstrated to work better than other models. When the SAFE score was applied to the US general population as seen in NHANES 17-20, 11% is categorised as high risk for F2+ fibrosis, 68% have steatosis and 31% have F2 or higher fibrosis. Seven percent have viral hepatitis, 13% have and only 20% have none of the above. Having fibrosis indicator as a tool to screen for advanced or chronic liver disease is a paradigm shift. In the current scenario, patients with incidental findings and abnormal ultrasound results. If fibrosis and not fat is added to diagnosis first, then it can help better manage. Only those with stage F2 get referred to hepatologists. However, this process needs an empowerment of primary care. Preventive hepatology can be practiced by gastroenterologists to refresh their interest in liver disease. Advanced Practice Providers (APPs) are important for GI practice, and they need to be empowered and trained for liver disease management.
Primary care providers need to be trained, motivated and provided with appropriate incentives for them to stay engaged in preventive hepatology. General hepatologists includes doctors with or without GI training.
The current model of hepatology as a post GI specialty has some pros and cons. The pros include performing endoscopy, band ligation and pre- and post- transplant care. However, that is not the skill set needed to impact the liver disease epidemic. The cons are spending 3 years learning how to manage IBD, how to deal with mortality patients, reflux problems, diarrhoea. There are limited GI fellowship sites, limited transplant jobs and pressure for high productivity.
Preventive hepatology needs to be an academic discipline we need to understand how to do this in an evidence-based fashion. Liver disease impact is increasing rapidly, whereas existing hepatology workforce is projected to dwindle. There is a need to go upstream and have minimal impact of innovations that we have had in cirrhosis. management and transplant. There is a need to detect and manage early stage liver disease. Preventive hepatology or secondary prevention of Chronic Liver Disease act as a nerve centre for holistic care of patients. There is a need for paradigm shift to screen populations for liver fibrosis and use SAFE score. There is need to train new generations of hepatologist with or without GI training preceding hepatology.
Digestive Disease Week (DDW) 2024, May 18-21, 2024, Washington, D.C.
