Do I need to refer a patient with hepatic steatosis for further evaluation and management?

Referral Decision for Hepatic Steatosis

Not all patients with hepatic steatosis require specialist referral—the decision depends entirely on fibrosis risk stratification using validated non-invasive tests, with only high-risk and indeterminate-risk patients needing hepatology evaluation. 1

Risk Stratification Algorithm

Step 1: Calculate FIB-4 Score

The finding of hepatic steatosis on imaging or unexplained abnormal liver enzymes should immediately trigger fibrosis risk assessment using the FIB-4 score (calculated from AST, ALT, age, and platelet count). 1, 2

Low-Risk Patients (No Referral Needed):

• FIB-4 <1.3 (or <2.0 if age >65 years) 1, 2
• These patients have high negative predictive value for advanced fibrosis and can be managed in primary care 1
• Repeat FIB-4 assessment in 2-3 years 1, 2
• Focus management on lifestyle interventions: 7-10% weight loss, Mediterranean diet, and metabolic risk factor optimization 1, 2

Important caveat: FIB-4 is not validated in patients under 35 years of age, so interpret with caution in younger populations. 1

Step 2: Secondary Testing for Indeterminate Risk

Indeterminate-Risk Patients (Consider Referral):

• FIB-4 1.3-2.67 requires second-tier testing 1, 2
• Obtain transient elastography (VCTE/FibroScan), Enhanced Liver Fibrosis (ELF) test, or magnetic resonance elastography (MRE) 1

VCTE thresholds for referral decision:

• <8.0 kPa: Low risk, manage in primary care with repeat surveillance in 2-3 years 1
• 8.0-12.0 kPa: Indeterminate, refer to hepatology for liver biopsy or MRE 1

• 12.0 kPa: High risk, refer to hepatology 1

ELF test thresholds:

• <7.7: Low risk 1
• 7.7-9.8: Indeterminate, consider referral 1

• 9.8: High risk, refer to hepatology 1

Step 3: Mandatory Referral Criteria

High-Risk Patients (Always Refer):

• FIB-4 >2.67 1, 2, 3
• VCTE >12.0 kPa 1
• ELF >9.8 1
• VCTE ≥20 kPa or thrombocytopenia (suggests cirrhosis—requires variceal screening) 1
• VCTE ≥15 kPa (highly suggestive of cirrhosis) 1

These patients require hepatology evaluation for consideration of liver biopsy, MRE, hepatocellular carcinoma screening, and variceal surveillance. 1

Critical Practice Points

The presence of steatosis alone does not determine referral need. Simple steatosis serves merely as a biomarker for potential steatohepatitis with fibrosis, but its presence or severity does not necessarily imply severe disease and should not be a treatment target per se. 1 The key predictor of liver-related morbidity and mortality is advancing fibrosis, not steatosis itself. 1

Cost-effectiveness data strongly supports this stratified approach. Implementation of FIB-4-based pathways resulted in a 5-fold increase in detection of advanced fibrosis, 3-fold increase in cirrhosis detection, and 81% reduction in unnecessary referrals of patients with mild disease. 1

Common pitfall: Normal liver enzymes do not exclude advanced fibrosis. ALT has only 50% sensitivity for NASH and 40% sensitivity for advanced fibrosis, and ALT typically falls as fibrosis progresses. 1 Never rely on normal liver tests to avoid fibrosis assessment. 1

For patients with type 2 diabetes or ≥2 metabolic risk factors: These high-risk populations warrant more aggressive screening and may benefit from sequential testing with a second non-invasive test even if initial FIB-4 is in the low-risk range. 1, 2