Which Healthcare Provider Should You See?
If your liver enzymes were normal 6 months ago, you should start with your primary care physician for repeat testing and initial evaluation, rather than going directly to a hepatologist. 1
Why Start with Primary Care
Normal liver enzymes 6 months ago do not guarantee current normalcy, and the first step is to confirm whether your liver enzymes are currently elevated through repeat testing. 2
Your primary care physician can order the appropriate initial blood work and calculate your FIB-4 score immediately using age, ALT, AST, and platelet count to assess your risk for liver fibrosis. 1
Primary care providers should handle the initial risk stratification and basic evaluation before specialist referral is considered. 2
When to See a Hepatologist
You should be referred to a gastroenterologist with an interest in liver disease or hepatologist if any of the following are found: 2, 1
- FIB-4 score >2.67 (indicating high risk for advanced fibrosis)
- Liver stiffness measurement >12.0 kPa on FibroScan (if performed)
- Evidence of cirrhosis or portal hypertension on imaging
- Persistently elevated liver enzymes with no identifiable risk factors for non-alcoholic fatty liver disease (such as diabetes, BMI >25, dyslipidemia, or hypertension) after extended liver screening
Initial Workup Your Primary Care Doctor Should Order
If liver enzymes are currently elevated, your primary care physician should: 1
- Calculate FIB-4 score using your age, ALT, AST, and platelet count
- Order an extended liver etiology screen including viral hepatitis serologies (hepatitis B and C), autoimmune markers, and metabolic screening (fasting lipids, hemoglobin A1c, iron studies)
- Order an abdominal ultrasound to evaluate for fatty liver, focal lesions, and biliary obstruction
- If FIB-4 is indeterminate (1.3-2.67) or high (>2.67), arrange for FibroScan/transient elastography to assess liver stiffness
Common Pitfall to Avoid
Do not assume that normal liver enzymes 6 months ago mean you can skip current evaluation. More than 30% of elevated liver enzymes can spontaneously normalize during follow-up, but conversely, new liver disease can develop within months. 3 The key is confirming your current status before deciding on the appropriate specialist pathway.