Improving the identification and monitoring of cirrhosis.

Morbidity and mortality associated with cirrhosis are on the increase. In a recent UK cohort study the incidence of cirrhosis increased by 50.6% between 1998 and 2009. Although all causes of liver disease increased during this period, this trend was primarily attributed to rising levels of alcohol misuse and obesity. Cirrhosis generally results from chronic liver damage over many years. It is characterised by fibrosis and nodularity of the parenchyma, which interferes with the synthetic, metabolic and excretory functions of the liver. Common causes include: alcohol misuse, hepatitis B (± delta) and hepatitis C and non-alcoholic fatty liver disease. Abdominal ultrasonography is a good first-line investigation in patients with suspected liver disease. The most commonly used serum biomarker is the enhanced liver fibrosis panel. Transient elastography is a specialist radiological test, which quantifies liver compliance. Compared with a standard biopsy, it will assess a much larger proportion of the liver and therefore sampling errors should be reduced. The measurements are painless and quick and serial measurements for monitoring treatment response e.g. in chronic viral hepatitis, are feasible and acceptable to patients. Patients with confirmed cirrhosis should be assessed for potential complications (ascites, encephalopathy, oesophageal varices or hepatocellular carcinoma). Reviewing cirrhotic patients regularly in primary care provides a valuable opportunity to ensure hepatocellular carcinoma and variceal surveillance is being undertaken and to give advice on losing weight or reducing alcohol intake.