The Curbsiders Internal Medicine Podcast REBOOT: #466 Cirrhosis Update with Scott Matherly
Nov 24, 2025
Scott Matherly, an associate professor of Hepatology and the transplant hepatology program director at Virginia Commonwealth University, shares his insights on cirrhosis management. He discusses the intricacies of diagnosing cirrhosis and highlights the significance of elastography and MR elastography. Matherly emphasizes the importance of physical exam clues and patient education, while detailing the risks associated with cirrhosis, including liver failure and hepatocellular carcinoma. He also dives into treatment strategies for decompensation and when to refer patients for transplant evaluation.
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Initial Cirrhosis Workup
- Send hepatitis B and C serologies, alpha-1 antitrypsin, ferritin/transferrin saturation, and autoimmune markers when evaluating suspected cirrhosis.
- Review imaging yourself and use FIB-4 to triage need for elastography or biopsy.
Use FIB‑4 As A Triage Tool
- Use FIB-4 in clinic as a quick negative-predictive test for advanced fibrosis and calculate it from age, AST, ALT, and platelets.
- If FIB-4 is above cutoffs or imaging and labs conflict, proceed to vibration-controlled transient elastography or MR elastography.
Endoscopy For Variceal Assessment
- Perform an upper endoscopy to screen for esophageal or gastric varices when you suspect clinically significant portal hypertension.
- Do not rely on CT alone because periesophageal findings may not reflect lumenal varices or gastric varices.
