When do I refer a patient with cirrhosis (scarring of the liver) to a specialist?

When to Refer Patients with Cirrhosis to a Specialist

All patients with cirrhosis should be managed by or in consultation with a gastroenterologist or hepatologist, and if this expertise is not available at your center, refer immediately to an expert center. 1

Immediate Specialist Referral Triggers

Decompensated Cirrhosis or Advanced Disease

• Refer urgently to a hepatologist linked to a transplant program for any patient with bilirubin >50 μmol/L (approximately 3 mg/dL) or evidence of decompensated liver disease (ascites, hepatic encephalopathy, variceal bleeding, hepatorenal syndrome). 1
• Patients with MELD score ≥15 require evaluation for liver transplantation and should be referred to a transplant center. 2
• Any clinical decompensation event (first episode of ascites, hepatic encephalopathy, or variceal bleeding) warrants specialist consultation, as median survival after onset of hepatic encephalopathy is 0.92 years and after ascites is 1.1 years. 3

Complex or High-Risk Presentations

• Refer to an expert center if considering transjugular intrahepatic portosystemic shunt (TIPS) placement, as this requires multidisciplinary evaluation by hepatology and interventional radiology with available critical care, cardiology, and transplant surgery services. 1
• Patients with hepatorenal syndrome (annual incidence 8% in those with ascites, median survival <2 weeks) require immediate specialist management. 3
• Suspected or confirmed hepatocellular carcinoma (HCC) necessitates referral to a hepatologist with transplant center access, as 1-4% of cirrhosis patients develop HCC annually with 5-year survival of only 20%. 3, 2

Ongoing Specialist Co-Management

All Cirrhosis Patients

• A gastroenterologist or hepatologist should be involved in ongoing management of all patients with established cirrhosis, regardless of compensation status. 1
• If you lack local hepatology expertise, establish a referral pathway to an expert center rather than managing in isolation. 1

Specific Clinical Scenarios Requiring Additional Consultation

• Portal hypertension complications (varices, refractory ascites) require hepatology consultation for endoscopic screening, beta-blocker prophylaxis, and diuretic management. 3, 4
• Patients with non-cirrhotic portal hypertension or varices without established cirrhosis need specialist evaluation. 1
• Complex cases may require additional specialty consultations (transplant surgery, cardiology, nephrology, hematology, neurology) on a case-by-case basis. 1

Palliative Care and Hospice Referral

Specialist Palliative Care Triggers

• Refer to specialist palliative care for refractory symptoms beyond your scope, difficult advance care planning discussions, complex care coordination, or challenging family dynamics. 1
• Patients with comfort-oriented goals and prognosis ≤6 months should receive timely hospice referral, ideally preceded by advance care planning discussions. 1
• Late or absent palliative care/hospice referral is common in cirrhosis but associated with worse outcomes; proactive referral improves quality of life and reduces procedure burden. 1

Common Pitfalls to Avoid

• Do not delay referral waiting for "very high" liver enzymes; persistent abnormalities over 3-6 months warrant specialist evaluation even if mildly elevated. 5
• Approximately 40% of cirrhosis patients are diagnosed only when presenting with complications—refer earlier based on noninvasive markers (elastography ≥15 kPa, thrombocytopenia, imaging findings) rather than waiting for decompensation. 3
• Do not manage cirrhosis in isolation if you lack hepatology support; shared care between primary care/general gastroenterology and hepatology specialists, particularly involving advanced practice providers, is associated with improved quality metrics, reduced 30-day readmissions, and lower mortality. 6
• Recognize that only one in three people with cirrhosis knows they have it—maintain high index of suspicion and low threshold for specialist referral when cirrhosis is suspected. 4