The Curbsiders Internal Medicine Podcast

Episode #466: Cirrhosis Update with Dr. Scott Matherly

Released: January 13, 2025

Episode Overview

This episode features Dr. Scott Matherly, Associate Professor of Medicine and Transplant Hepatology Fellowship Director at Virginia Commonwealth University. The discussion takes a deep dive into the initial evaluation and management of cirrhosis, covering diagnostic approach, key workup and imaging, managing decompensation, practical clinical pearls, HCC surveillance, dietary and medication counseling, and when to refer for transplant. The conversation is rich with actionable advice and clinical wisdom, relevant for any internal medicine, family medicine, or primary care provider.

Key Discussion Points and Insights

1. Getting to Know Dr. Matherly [[03:39]]

• Dr. Matherly shares updates since his last appearance (“I’ve had two more kids… and I started doing competitive powerlifting. That’s my midlife crisis.”)
• Favorite failure: Did not match into GI fellowship first time; this failure redirected his career and passion (“From that failure has come my entire career and my passion, what I do…” — Dr. Matherly, [05:32])

2. Case Introduction & Initial Diagnostic Approach [[08:10]]

Presented Case: Paulina, 57F, obesity, Roux-en-Y gastric bypass, past alcohol use, found incidentally to have hepatic nodularity and splenomegaly on CT.

Etiology & Labs to Send [[08:57]]

• Considered Etiologies: Metabolic/steatotic liver disease (fatty liver), alcohol–especially significant after gastric bypass due to increased risk.
• Initial Workup
  • Basic labs: CBC, liver enzymes (AST, ALT, ALP), INR, bilirubin, albumin, creatinine, sodium.
  • Serologies: Hepatitis B (surface antigen, core ab), Hepatitis C ab.
  • Genetic/metabolic: Alpha-1 antitrypsin, ferritin, transferrin saturation, possibly ceruloplasmin.
  • Autoimmune markers (ANA, SMA, AMA) especially in female patients.
• Review Imaging Yourself: “I would pull it up myself, look at the liver, measure the portal vein, look at the spleen… Not uncommon for people to get labeled cirrhosis that don’t actually have it.” — Dr. Matherly, [10:55]

3. Interpreting Labs and Next Diagnostic Steps [[11:51]]

• Example labs: Mildly elevated AST/ALT, low-ish platelets, normal INR/albumin.
• Fibrosis Calculator
  • Use FIB-4 (AST, ALT, platelet, age): “My bias is to use what’s called the FIB-4... It’s a very useful tool… particularly as a negative predictive test.” — Dr. Matherly, [13:41]
  • If FIB-4 is low (<1.3 for fatty liver/<1.45 for viral): Good negative predictive value.
  • If FIB-4 is above: “Further investigation would be recommended.” (e.g., VCTE/FibroScan, MR Elastography, or referral to hepatology)
  • Elastography Options: Vibration controlled transient elastography (FibroScan) is practical and noninvasive; MR elastography more sensitive but expensive and less accessible. [[19:15]]

When Labs & Imaging Conflict [[21:50]]

• “If you have conflicting data, you need a tiebreaker… that would either be vibration controlled transient elastography or a liver biopsy.” — Dr. Matherly

4. Physical Exam, Imaging, and Portal Hypertension Signs [[23:49]]

• Focus on hands (Terry’s nails, palmar erythema), spider angiomata, evidence of fluid overload.
• Splenomegaly and portal vein diameter are suggestive but nonspecific alone.

5. Variceal Screening and Beta Blocker Use [[24:59]]

• CT showing varices? Gold standard remains upper endoscopy prior to beta blocker initiation.
• Beta Blocker Shift: “Carvedilol is the preferred beta blocker in portal hypertension… head-to-head trials [show it] lowers portal pressures more.” — Dr. Matherly, [27:13]
• Dosing: Start at 6.25 mg once daily → increase to 6.25 mg BID as tolerated (max 12.5 mg BID). Don’t titrate by pulse; only stop for SBP <90.
• Screening: “If you think the patient has cirrhosis, they need an upper endoscopy, and that’s who we screen.” [32:04]

6. General Patient Counseling: Diet, Complications, and Education [[33:09]]

• Emphasize education at diagnosis; patients come with fear, stigma.
• The “four ways cirrhosis can kill you” (mnemonic for patients) [[38:31]]:
  1. Liver failure (progressive, risk reduction via addressing etiology or transplant)
  2. Bleeding (varices/portal hypertension, risk reduced via screening/intervention)
  3. Liver cancer (3–5%/year risk → HCC screening & early detection)
  4. Malnutrition/infection (ascites, sarcopenia, SBP)
• Dietary Guidance:
  • “I am usually very pro-calories and pro-protein for my patients.”
  • Protein shakes to prevent sarcopenia; late evening snack (e.g., apple with peanut butter).
  • Sodium: Not super strict, but educate “the more salt you eat, the more fluid you’re going to hold on to.” Sodium restriction can worsen frailty if patients undereat.
• Medication Counseling:
  • “You can take acetaminophen”—dose ≤2000 mg/day is safe.
  • Statins: Safe in compensated cirrhosis (and may be beneficial); discontinue only if decompensated.
  • Avoid NSAIDs, herbal supplements, “liver cleanses.”

Notable Quote:

“Be on the lookout for liver disease because it’s out there and it’s everywhere… Our goal is to keep people compensated.” — Dr. Matherly, [77:58]

7. HCC Surveillance [[47:26]]

• Ultrasound every 6 months (+/- AFP); sensitivity declines in fatty liver/high BMI/advanced disease, so if limited, alternate/augment with MRI (preferred) or CT.
• Review the quality of imaging and act on suboptimal studies (“If the ultrasound is suboptimal…I will alternate with some cross sectional imaging, preferably MRI…”).

8. Decompensated Cirrhosis: Definitions and Importance [[50:03]]

• Decompensation = development of overt portal hypertension complications: ascites, variceal bleeding, or hepatic encephalopathy.
• “Once a patient decompensates, their survival really goes down fairly dramatically.” — Dr. Matherly
• Once decompensated, always labeled so (“clinically recompensated” if great recovery, but risk remains).

9. Management Pearls: Ascites, SBP, Encephalopathy [[53:55]]

• Ascites
  • Loop diuretic (furosemide):spironolactone in 1:2.5 ratio; typically start 40:100 mg once daily, titrate in steps.
  • Sodium restriction as above.
  • If refractory or requiring frequent paracenteses, consider evaluation for TIPS.
• SBP
  • High mortality; “tap early and tap often”—diagnostic paracentesis for any symptom.
• Encephalopathy
  • Not a reason to reduce protein intake (“We should never be protein restricting a patient with cirrhosis for this…” — Dr. Matherly, [57:41])
  • Lactulose preferred over polyethylene glycol (Miralax): “There’s magic in lactulose.”
  • Rifaximin as second line (use liberally but limited by cost).
  • Don’t use ammonia levels for titration/diagnosis; make it clinical.

10. TIPS and Portal Hypertension [[61:43]]

• What is TIPS? Shunt to lower portal pressure, helps varices/refractory ascites.
• Risks: Encephalopathy (30–40% post-TIPS), can worsen heart failure, cautious with poor kidneys.
• Criteria:
  • HVPG >10mmHg (“clinically significant”)
  • Practically, presence of varices or ascites means portal hypertension.
  • Noninvasive surrogate: liver stiffness (FibroScan), platelets.
• After TIPS: Gradually lower diuretics; not everyone is a candidate.
• “When you mess with portal hypertension, you don’t know what you’re going to get on the other end…” — Dr. Matherly

11. MELD Score and Referral for Transplant [[68:52]]

• MELD 3.0 now standard: adds albumin, biological sex, creatinine capped at 3 (vs. 4), adjusts weighting for equity.
• “7 is normal… 15 is where we start thinking about transplant.” — Dr. Matherly, [72:01]
• Transplant Referral:
  • Any decompensating event = referral point.
  • “Let the transplant center make social/behavioral judgments, not the referring provider.” (E.g., “Six months abstinence” is outdated.)
  • Living donor transplants allow listing despite lower MELD scores.

Notable Quotes & Memorable Moments

• On FIB-4 Use:
  “If a FIB-4 is low, then that is suggestive a patient does not have advanced fibrosis… I use this as a test to tell me: should I not be worried…” — Dr. Matherly, [13:41]

• On Patient Counseling About Cirrhosis’s Four Killers:
  “Number one is liver failure… number two is bleeding… third is liver cancer… and the fourth way cirrhosis can kill you is with malnutrition and infection.” — Dr. Matherly, [38:31]

• On Medication Counseling:
  “You can take acetaminophen. That’s what we tell people on our transplant list… (≤2000mg/day).” — Dr. Matherly, [43:25]

• On Early Referral for Liver Transplant:
  “…any decompensation—even the first one—their survival goes down dramatically… get them to a transplant hepatologist…” — Dr. Matherly, [73:49]

• On Navigating Conflicting Imaging and Labs:
  “If you have conflicting data, you need a tiebreaker of some sort. I would not…just say, ‘oh, there’s nothing to worry about here.’” — Dr. Matherly, [21:50]

Important Timestamps

• [03:39] Dr. Matherly’s updates and career “favorite failure”
• [08:57] Initial approach to a new diagnosis of cirrhosis
• [13:41] FIB-4 and non-invasive fibrosis evaluation
• [19:15] Elastography and imaging modalities for staging
• [24:59] Managing imaging findings of varices, role of EGD, and beta blocker selection/dosing
• [33:09] Patient counseling and lifestyle/dietary advice
• [38:31] The “four ways cirrhosis can kill you,” explained for patients
• [47:26] HCC surveillance: modalities, frequency, and special patient populations
• [50:03] Definition and implications of decompensated cirrhosis
• [53:55] Initial and escalated management of ascites, SBP, and hepatic encephalopathy
• [61:43] Definition and management of portal hypertension, overview of TIPS
• [68:52] MELD score, MELD 3.0, and transplant evaluation referral tips
• [73:49] When to refer for transplant—early is best

Take-Home Points

• Do not fear the liver—it’s everywhere, especially with the fatty liver epidemic.
• Early diagnosis and referral matter: “Once decompensated, survival drops sharply.”
• Use FIB-4 and elastography for non-invasive staging, but recognize their limits.
• Endoscopy remains the gold standard for variceal screening; carvedilol is preferred for portal hypertension.
• Counsel patients to eat enough protein/calories—prevention of sarcopenia is crucial.
• Acetaminophen is the safest pain medication (≤2g/day).
• Refer to transplant early with any decompensation, not just for high MELD.
• HCC screening is every 6 months with ultrasound + AFP, but consider alternatives in poor imaging candidates.
• Let transplant centers make social/behavioral eligibility judgments.
• Most importantly: pay attention to liver clues in labs and images—act earlier, not later.

For show notes, links, and more, visit TheCurbsiders.com. CME credit available through VCU Health.