Gastroenterologists should ‘start to own,’ embrace role in care for chronic liver disease
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Chronic liver disease is the ninth leading cause of death in the United States, independent of liver cancer. According to the CDC, only 1.8% of adult Americans have a diagnosis of chronic liver disease, which translates to 4.5 million people.
That sounds like it should be easily managed by the 7,296 hepatology providers reported in 2018, defined as hepatologists, gastroenterologists and advanced practice providers whose practice was at least 50% hepatology. However, more than 100 million people in the U.S. have liver disease — most are just not diagnosed.
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Metabolic dysfunction-associated steatotic liver disease alone affects 24% to 48% of the North American population, and 43% of the population drinks alcohol, according to a study published in the Journal of Hepatology. Even if you narrow the hepatology need to the subset of patients with metabolic dysfunction-associated steatohepatitis and those with alcohol use disorder at risk for liver injury, the number of impacted individuals is substantial — potential patients to providers rockets to 13,706. In Hepatology, a recent model confirmed that there is an impending critical shortage of adult and pediatric hepatology providers in the U.S.
A lack of dedicated hepatology providers is not the only reason gastroenterologists should start to own liver disease. Just like real estate: location, location, location. Most of the hepatology workforce centers around transplant centers, yet most patients with liver disease do not live in these locations. Connecting patients to accessible providers saves lives.
A recent retrospective cohort study published in Clinical Gastroenterology and Hepatology found that chronic liver disease patients who lived far away from a transplant center had higher mortality rates. This was especially apparent for the 5.2% of individuals who lived at least 150 miles from the closest transplant center.
Surprisingly, inclusion of rural or urban status did not attenuate the association between distance and survival — rural patients who lived in proximity to a transplant center had similar survival to urban patients. Equally surprising, zip-code level poverty also was not associated with survival in this analysis.
But the most compelling argument for gastroenterologists’ investment is prevention in a population of patients already receiving care in their clinics for colorectal cancer screening and GI symptoms. Most liver-related mortality is from complications of cirrhosis or liver cancer, both of which could be avoided with early recognition and surveillance protocols.
In addition, the most common causes of cirrhosis include viral hepatitis, alcohol and MASLD, all of which have easy screening tools to improve disease recognition. This is also exciting news for clinicians caring for individuals with liver disease, as these conditions can be stabilized, reversed and even cured.
Gastrointestinal and hepatology societies have produced easy care pathways to facilitate recognition and treatment. These tools also provide recommendations on how to comanage these conditions with primary care and hepatology.
In this cover story, Sujit V. Janardhan, MD, PhD, Dipl ABOM, Brian Kim, MD, Tatyana Kushner, MD, MSCE, and Amit Singal, MD, MS, provide their perspectives on the changing epidemiology and prevalence of MASLD, viral hepatitis, alcohol-associated liver disease and liver cancer and the importance of GI involvement. Their arguments highlight the importance of the gastroenterologist in the care cascade and should empower gastroenterologists to embrace their role in the management of chronic liver disease.
- References:
- Chronic liver disease and cirrhosis. https://www.cdc.gov/nchs/fastats/liver-disease.htm. Accessed Jan. 22, 2024.
- Devarbhavi H, et al. J Hepatol. 2023;doi:10.1016/j.jhep.2023.03.017.
- Goldberg DS, et al. Clin Gastroenterol Hepatol. 2017;doi:10.1016/j.cgh.2017.02.023.
- Russo MW, et al. Hepatology. 2020;doi:10.1002/hep.31425.
- For more information:
- Nancy S. Reau, MD, FAASLD, AGAF, is professor and associate director of organ transplantation at Rush University. She can be reached at nancy_reau@rush.edu.
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