When should I consider referring a patient with PBC to a specialist for further evaluation or management?

Consider referring a patient with primary biliary cholangitis (PBC) to a specialist hepatologist or gastroenterologist for further evaluation or management if:

• They have evidence of cirrhosis or advanced liver fibrosis, as specialist assessment is important for prognosis, management, and potential eligibility for liver transplantation.
• They show signs of decompensated liver disease, such as ascites, encephalopathy, or gastrointestinal bleeding, which require urgent specialist input.
• They have abnormal liver blood tests with a cholestatic pattern (raised alkaline phosphatase and bilirubin), which warrants specialist evaluation to confirm diagnosis and initiate treatment.
• They require assessment for complications of liver disease or consideration of specific treatments such as ursodeoxycholic acid or second-line therapies.
• They have symptoms or signs suggestive of progression or complications of PBC, including fatigue, pruritus, or portal hypertension.

Referral should be made early to ensure appropriate specialist management, monitoring, and support, as PBC is a chronic progressive liver disease that benefits from specialist care to prevent progression and manage complications.

This approach aligns with recommendations to refer patients with cirrhosis or significant liver disease to hepatology specialists for assessment and management ²,⁴. Additionally, patients with cholestatic liver test abnormalities should be referred to a gastroenterologist or liver clinic for further evaluation ¹.