The edition · Internal Medicine
Fatty liver: one score earns its place for cirrhosis follow-up, none for liver cancer
An 853,000-patient VA cohort ranks nine risk scores for steatotic liver disease. Also: hospital-to-clinic linkage for alcohol use disorder, why the cirrhosis SBP cut-off misleads in malignant ascites, and meals after discharge.
The edition in brief
In 853,131 US veterans with imaging-confirmed steatotic liver disease, 4.0% developed cirrhosis and 0.35% hepatocellular carcinoma within 10 years. FIB-4, APRI and the SAFE score discriminated cirrhosis best, and SAFE gave the greatest net benefit: a SAFE score of 29.5 marked a 10-year cirrhosis risk of 2.5%. No score was useful for deciding HCC surveillance in patients without cirrhosis. A systematic review in Annals found only 8 of 21 hospital-based interventions improved outpatient follow-up after an admission with alcohol use disorder; the ones that worked combined behavioural support and care coordination with medication or social support, and certainty was low. A single-centre study of 337 paracenteses suggests the cirrhosis threshold of 250 PMN/mm3 has specificity of only 72% for bacterial peritonitis in malignant ascites. A retrospective cohort linked two weeks of home-delivered meals after discharge with lower 14-day readmission in food-insecure older adults (aOR 0.31), fading by 30 days.
Alcohol use disorder: the discharge bundle matters more than any one piece
Before discharging a patient admitted with alcohol use disorder, start medication where suitable and hand them a booked appointment and a named contact.
Malignant ascites: the 250 PMN cut-off borrowed from cirrhosis does not fit
Do not diagnose or exclude bacterial peritonitis in malignant ascites on the 250 PMN cut-off alone; culture every tap and judge the whole picture.
Two weeks of meals after discharge linked with fewer early readmissions
Screen older patients for food insecurity before discharge and arrange meals for the first fortnight at home where you can.
Choosing an AUD drug for the patient on your ward
Pick acamprosate for liver disease, naltrexone for poor renal function, and never naltrexone alongside opioids.
Steatotic liver disease: use SAFE or FIB-4 to decide who needs cirrhosis follow-up
When imaging shows a fatty liver, calculate FIB-4 or SAFE to decide who needs cirrhosis work-up; do not use any score to start HCC surveillance without cirrhosis.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for internal medicine, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free