Early Liver Disease Detection Starts in Primary Care: A Q&A With Stevan Gonzalez, MD

Chronic liver disease frequently remains undetected until fibrosis, cirrhosis, or other complications have developed, in part because patients may have no symptoms during earlier stages. This places primary care clinicians in a critical position to identify risk factors, investigate abnormal laboratory or imaging findings, and initiate screening before advanced disease is present.

In the following Q&A, Stevan Gonzalez, MD, MS, director of Liver Transplantation at Baylor Scott & White All Saints Medical Center in Fort Worth, Texas, discusses the populations most likely to be missed, practical opportunities for earlier detection, and why identifying liver disease before symptoms develop can substantially alter its course.

Q: Why do so many cases of liver disease go unnoticed until they have already become serious? What early signs should clinicians be paying attention to?

Gonzalez: “That’s a challenge with virtually all forms of liver disease. The liver is a vital organ that is continuously working for us every single day, but it’s silent. We don’t see our liver, we don’t feel our liver, and so if a person has a chronic liver disease, the liver is actually a very resilient organ that will continue doing that work every single day, without any complaints, without any symptoms.”

Although patients may not report symptoms, chronic injury can continue and eventually produce fibrosis.

Gonzalez: “That injury to the liver related to a chronic disease can be happening, and over time, the concern is that can create scar tissue in the liver, what’s known as fibrosis. That’s why it’s important to follow up through primary care and continue following up so that an individual person, a patient, can get screened if they have risk factors or any abnormalities that suggest there could be a liver disease.”

He cited hepatitis C screening as a clear example of how primary care can identify treatable disease before complications occur.

Gonzalez: “There are screening recommendations for things like hepatitis C, where it’s recommended for every adult in the U.S. to be screened at least one time for hepatitis C. It could be done through your primary care doctor’s office. If we diagnose hepatitis C, for example, as a silent liver disease that could be creating injury and a risk of cirrhosis, it’s a curable infection, and the treatment is very well tolerated.”

Q: What can patients do to protect liver health before symptoms develop?

For clinicians, preventive counseling should focus heavily on the 2 most common drivers of chronic liver disease in the United States: alcohol use and metabolic risk.

Gonzalez: “The two biggest reasons to have liver disease in the U.S. right now are alcohol-associated liver disease and something we commonly refer to as fatty liver disease. It’s called metabolic dysfunction-associated steatotic liver disease. It’s related to diabetes and obesity.”

He emphasized diet, physical activity, weight management, and alcohol exposure as central targets for intervention.

Gonzalez: “The two main causes of liver disease in the U.S. are related to things that are associated with our lifestyle in terms of our diet. Thinking about, do we follow a low-fat diet? Do we exercise? Avoiding obesity and being careful in terms of alcohol use.”

Gonzalez also noted that alcohol-associated liver disease accelerated during the COVID-19 pandemic and has disproportionately affected certain populations.

Gonzalez: “Alcohol-associated liver disease was actually increasing at a gradual pace in the United States, and then in 2020 we just saw this upward shift where a significant increase occurred, and it coincided directly with the COVID-19 pandemic. What’s concerning is that that was in 2020, but that has persisted.”

Gonzalez: “There are groups of populations in the U.S. who are disproportionately affected by alcohol-associated liver disease, and that includes women, younger people, Native Americans. There are groups that we have to be careful about because they have had a significant increase in alcohol-associated liver disease that’s more than in the past.”

Q: What role can community health programs and local clinics play in detecting liver disease earlier?

Because the overall burden of liver disease exceeds specialist capacity, Gonzalez said screening and risk recognition must increasingly occur in primary care and community-based settings.

Gonzalez: “What we’re recognizing is that chronic liver disease in the U.S. is vastly underestimated, and it’s beyond what, for example, a specialist like myself, a liver specialist, can do in terms of the general population. That’s where our primary care providers and our community-based health organizations are going to play a very important role in increasing awareness, education, and screening.”

He encouraged clinicians to identify local screening resources for patients who lack ready access to specialty care.

Gonzalez: “For someone who doesn’t have access, check to see if there are local organizations and community health fairs where they are doing screening for liver disease. There are examples of that, and we’re trying to increase that nationwide. But it’s really based on community efforts, so you have to explore your own community to see what’s available.”

Q: Where are the major gaps in community-based screening and outreach?

Access remains one of the largest barriers, particularly because several high-risk populations are also less likely to engage routinely with the health system.

Gonzalez: “I think a key point here is access, and there are populations who you would consider actually at risk based on socioeconomic factors and who may not actually have access to health care. Unfortunately, they are in some of the highest-risk categories for things like viral hepatitis.”

For hepatitis B, he pointed to the importance of screening individuals from endemic regions, even as vaccination has reduced overall US prevalence.

Gonzalez: “Hepatitis B, which we rarely see because vaccination has had such an incredible impact in reducing the prevalence of hepatitis B in the United States, but people who are immigrants from countries where it’s an endemic disease, they need to be screened for hepatitis B.”

For hepatitis C and metabolic liver disease, outreach may be required to reach patients affected by homelessness, incarceration, injection drug use, or food insecurity.

Gonzalez: “Hepatitis C disproportionately affects groups that may not necessarily go and seek health care, including homeless, incarcerated, injection drug use. And then fatty liver disease can be associated with people who may not be following a good diet, food insecurity, things like that.”

Gonzalez: “Those are examples of chronic liver diseases that are affecting people that may not necessarily be seeking health care on a regular basis. That just kind of shows you the need to really outreach to those communities in an effort to reduce the burden of liver disease in the U.S.”

Q: What practical strategies can clinicians use to identify at-risk patients and determine when further evaluation is needed?

Gonzalez said clinicians should begin with a structured assessment of metabolic, alcohol-related, familial, and viral hepatitis risk.

Gonzalez: “There are certain risk factors that are associated with an at-risk population who should be screened for liver disease. That includes people who have diabetes, people who have obesity and some other risk factors like high cholesterol, high blood pressure, those who have a family history of liver disease.”

Alcohol history is another essential component of routine evaluation.

Gonzalez: “People who have a history of excessive alcohol use. Just through a provider taking a history, a medical history, and then understanding their alcohol use, that may raise some concerns related to risk of liver disease.”

Clinicians should also consider country of origin and prior exposures that increase the likelihood of viral hepatitis.

Gonzalez: “Anyone who may have had some high-risk exposures or come from a country that has exposures to things like hepatitis B, for example.”

Abnormal liver tests and incidental imaging findings should not be dismissed, particularly when they suggest steatosis, fibrosis, or cirrhosis.

Gonzalez: “If during their usual medical care they identify abnormal liver function tests or a scan, an imaging study that reveals an abnormality of the liver, like fatty liver or a suggestion that there’s cirrhosis, those are all individuals who may need further screening for liver disease.”

Q: Why does earlier diagnosis matter as more therapies become available?

The clinical value of screening is not limited to documenting disease. Gonzalez emphasized that many forms of chronic liver injury can stabilize or improve when identified and treated before cirrhosis develops.

Gonzalez: “Many people will ask, ‘What’s the point? Why do we need to screen or recognize, identify people with liver disease at an early time point?’ The reason is that, getting back to the nature of the liver as a vital organ, it’s also an organ that’s capable of repairing itself.”

Gonzalez: “Many of these conditions, even if a person does have evidence of advancing or progressive liver disease, it’s reversible. It’s actually reversible.”

He said that opportunity extends across metabolic, alcohol-associated, and viral liver disease.

Gonzalez: “That includes fatty liver disease, what we refer to as metabolic dysfunction-associated fatty liver, alcohol-related liver disease, and even viral hepatitis. It can be treated, and then we can actually stop the progression of their liver disease.”

Gonzalez: “You can actually avoid cirrhosis, and the liver can actually return to an improved function and move further away from cirrhosis.”

Editor’s Note: Gonzalez reports relevant disclosures with Mallinckrodt Pharmaceuticals, Salix, AbbVie, Gilead, and others.