American Association for the Study of Liver Diseases

Five Things Physicians and Patients Should Question

Released June 15, 2014

  1. 1

    Don’t perform surveillance esophagogastroduodenoscopy (EGD) in patients with compensated cirrhosis and small varices without red signs treated with non-selective beta blockers for preventing a first variceal bleed.

    In patients with cirrhosis and small varices that have not bled and have no criteria for increased risk of bleeding (Child A, no red signs on varices), beta blockers can be used. In patients with cirrhosis and medium or large varices that have not bled and are not at the highest risk of bleeding (Child A and no red signs), beta blockers are preferred, adjusted to the maximal tolerated dose. In both scenarios, follow-up EGD is not necessary.

  2. 2

    Don’t continue treatment for hepatic encephalopathy indefinitely after an initial episode with an identifiable precipitant.

    In circumstances where the precipitating factors are identified and well-controlled (e.g., recurrent infections, variceal bleeding) or liver function or nutritional status improved, prophylactic therapy may be discontinued.

  3. 3

    Don’t repeat hepatitis C viral load testing outside of antiviral therapy.

    Highly-sensitive quantitative assays of hepatitis C RNA are appropriate at diagnosis and as part of antiviral therapy. Otherwise, the results of virologic testing do not change clinical management or outcomes.

  4. 4

    Don’t perform computed tomography or magnetic resonance imaging routinely to monitor benign focal lesions in the liver unless there is a major change in clinical findings or symptoms.

    Patients with benign focal liver lesions (other than hepatocellular adenoma) who don’t have underlying liver disease and have demonstrated clinical and radiologic stability do not need repeated imaging.

  5. 5

    Don’t routinely transfuse fresh frozen plasma and platelets prior to abdominal paracentesis or endoscopic variceal band ligation.

    Routine tests of coagulation do not reflect bleeding risk in patients with cirrhosis and bleeding complications of these procedures are rare.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Association for the Study of Liver Diseases (AASLD) is the leading organization of scientists and health care professionals committed to preventing and curing liver disease. AASLD was founded in 1950 by a small group of leading liver specialists to bring together those who had contributed to the field of hepatology.

AASLD has grown to an international society responsible for all aspects of hepatology, and our annual meeting, The Liver Meeting®, has grown in attendance from 12 to more than 9,500 physicians, surgeons, researchers and allied health professionals from around the world.

Hepatology has been recognized as a discipline only in the last few decades, and AASLD played a seminal and unifying role in focusing interest on hepatological problems, as well as the founding of other hepatological societies.

To learn more about the AASLD, visit

How This List Was Created

The American Association for the Study of Liver Diseases (AASLD) established a Choosing Wisely® Task Force in December 2013 to develop its list of recommendations. Members of this group were selected from the AASLD Practice Guidelines Committee to broadly represent varying practice settings and subspecialty expertise within the field of hepatology. Hepatologists with methodological experience in evidence-based medicine were also included. The working group solicited recommendations from the entire AASLD membership that should be considered for inclusion in the list of “Five Things Physicians and Patients Should Question”. These recommendations were then rated based upon judgments related to harm, benefit and excess resource utilization. Based on working group voting and literature review, a total of 10 suggestions were identified with subsequent voting by the working group to generate the final Top Five recommendations. These recommendations were submitted and approved by AASLD Governing Board.

AASLD’s disclosure and conflict of interest policy can be found at


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