What are the indications for referring a patient with cirrhosis to a specialist?

Indications for referring a patient with cirrhosis to a specialist include:

• If the patient has signs of decompensated liver disease such as ascites, hepatic encephalopathy, or gastrointestinal haemorrhage, arrange emergency hospital admission or immediate referral to a hepatologist or gastroenterologist with an interest in hepatology depending on clinical judgement.
• If cirrhosis is diagnosed by transient elastography or other imaging and the patient is not already under specialist care, arrange referral to a hepatologist or gastroenterologist.
• Patients who have, or are at high risk of, complications of cirrhosis should be referred to a specialist hepatology centre.
• Patients with alcohol-related liver disease should be considered for referral to specialist alcohol services for support.
• Early referral to a multidisciplinary palliative care team is indicated for patients with end-stage liver disease, including those with end-stage decompensated cirrhosis, ongoing alcohol use with decompensated alcohol-related liver disease, irreversible decompensated disease unsuitable for liver transplantation, two or more unplanned liver-related admissions in the last 6 months, or hepatocellular cancer where best supportive care is appropriate.
• Patients with suspected or confirmed clinically significant portal hypertension may require specialist treatment and surveillance, including upper gastrointestinal endoscopy for varices and hepatocellular carcinoma surveillance.
• Adults who are hepatitis B surface antigen positive should be referred to a hepatologist or gastroenterologist with an interest in hepatology for assessment and management.

Following specialist assessment, some patients may be managed in primary care using a shared-care approach, but initial referral is essential for diagnosis confirmation, risk stratification, and management planning.

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