Using tips and tricks from his own medical tool box, Michael B. Fallon, MD, FAASLD, Executive Director for Clinical Research and Professor, Chair, Department of Medicine, University of Arizona College of Medicine Phoenix, offered practical advice for screening for four conditions tied to cirrhosis during the Advances for Practitioners session at The Liver Meeting®.
“Some of these recommendations are provisional, and some are based somewhat on my own assessment of cases,” said Dr. Fallon as he outlined research on and options for screening for minimal hepatic encephalopathy (MHE), frailty, varices and hepatocellular carcinoma.
MHE is fairly common in patients with cirrhosis, he noted, adding that it can be found in 50%-60% of these patients.
“There is an increased risk of overt hepatic encephalopathy, impaired driving, mortality and poor quality of life,” said Dr. Fallon.
While multiple psychometric tests can be used, there are inconsistent correlation with outcomes. He said the Stroop test is relatively good at predicting MHE.
“I use it in patients in specific situations. I don’t screen everybody,” he explained. “I screen patients where there’s caregiver concern, quality of life, concern for the patient and family and then patients who had were vehicle accidents or violations.”
When it comes to frailty screening measures, simple objective and qualitative scoring systems are in use. He noted integrating screening for functional, cognitive and decompensation components may improve outcomes.
“Frailty is very common on the waiting list,” said Dr. Fallon, who noted that frailty in hepatic encephalopathy may be linked by the presence of sarcopenia.
He described a multi-pronged approach to frailty screening that encompasses cardiopulmonary evaluations, psychometric and cognitive testing, and liver specific screening.
The Liver Frailty Index (LFI), which has been developed and validated at University of California-San Francisco, is “better than an eyeball test,” he said. The LFI considers gender, grip, chair stands, and balance.
Screening for varices, he noted, is based on the progression of cirrhosis and portal hypertension.
“You can use noninvasive tests to predict varices needing treatment and reduce the endoscopy burden in compensated disease,” he said.
In regard to hepatocellular carcinoma screening, he said ultrasound with or without alpha fetoprotein at six month intervals in appropriate risk groups is recommended.
“Sensitivity and data supporting utility are suboptimal, and compliance with testing is still a challenge,” said Dr. Fallon. “Enhanced screening will need to incorporate multiple techniques including biomarkers.”