The American College of Gastroenterology (ACG)1 recommends screening individuals with heavy alcohol use for liver disease. Universal screening for alcohol use is most applicable in the primary care setting because it is where patients with heavy alcohol use and alcohol-related liver disease may be identified before they develop advanced liver damage. Once these patients present to a gastroenterology clinic, their liver disease is often significantly progressed or even irreversible.2 However, liver disease screening in individuals with heavy alcohol use is currently not standard in primary care, in part because no major primary care organizations have followed the ACG in endorsing this practice.
In this commentary, we make the case that screening patients with heavy alcohol use for liver disease is a valuable tool for primary care clinicians to consider. To this end, we review the existing literature on screening methods, outline ongoing research that will inform this topic in the future, and propose a simple screening pathway for primary care.
PREVALENCE OF ALCOHOL-RELATED LIVER DISEASE IS INCREASING
Approximately 2.6% of Americans, or 5.7 million people, have cirrhosis,3 and it is estimated that 45% of cirrhosis diagnoses are related to alcohol use.4 The prevalence of cirrhosis has doubled over the past decade, and once patients progress to end-stage liver disease (also known as decompensated cirrhosis), their prognosis is grim.5 Median survival for patients with decompensated cirrhosis is comparable to, if not worse than, many advanced cancers. Unlike most cancers, though, cirrhosis can be prevented if those at risk are identified early.
Alcohol use is a modifiable risk factor, and it accounts for a large share of cirrhosis cases and mortality. Indeed, age-adjusted mortality rates from alcohol-related liver disease doubled between 1999 and 2022.6 According to the ACG,1 patients who engage in heavy drinking are at risk of alcohol-related liver disease. The National Institute on Alcohol Abuse and Alcoholism7 defines heavy drinking as follows:
For men: consuming 5 or more drinks on any day or 15 or more drinks per week
For women: consuming 4 or more drinks on any day or 8 or more drinks per week.
Over 16 million Americans engage in heavy drinking.8 Many of these patients may not meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,9 criteria for alcohol use disorder, so the health consequences of their heavy alcohol use are discussed largely in primary care settings rather than in specialty psychiatric or addiction medicine clinics.
EVIDENCE SHOWS EARLY INTERVENTION CAN BENEFIT PATIENTS
Targeted liver disease screening in primary care for those who drink heavily could result in improved population health outcomes.
Existing health inequities are deepened by the disproportionate and worsening burden of alcohol-related liver disease among working-class Americans
Between 1992 and 2021, among Americans without a college degree, mortality from alcohol increased approximately 81% (from 21 per 100,000 people in 1992 to 38 in 2021) but increased minimally among those with a college degree (from 11 per 100,000 people in 1992 to 13 in 2021).10 A similar education gap emerged in deaths from liver cancer, which nearly doubled among those without a college degree but changed minimally among degree holders.10
Effective alcohol use disorder treatment and counseling can prevent alcohol-related liver disease
Indeed, pharmacologic treatment of alcohol use disorder decreases incidence and prevalence of alcohol-related liver disease.11 Furthermore, in patients with heavy alcohol use, liver disease screening can inform both diagnosis and treatment of alcohol use disorder. Patients who continue to drink despite known liver damage may meet diagnostic criteria for alcohol use disorder,9 which should prompt more intensive interventions, including consideration of pharmacotherapy for alcohol use disorder (Table 1)12–15—a highly effective but remarkably underused tool.16
Pharmacotherapy for alcohol use disorder
Liver disease screening has also been shown to change behavior
For one, patients with heavy alcohol use are interested in learning about the effects of alcohol on their liver.17 A few studies have investigated how screening with transient elastography, an ultrasonography-based technology that assesses liver stiffness, affects care. In a prospective cohort study of 86 patients in the United Kingdom who were screened with transient elastography, alcohol consumption decreased meaningfully in patients not only with elevated liver stiffness but also with normal findings.18
A randomized controlled trial by the same research group showed that incorporating liver transient elastography into alcohol addiction treatment clinics was feasible.19 Furthermore, patients randomized to transient elastography had higher engagement in care and greater decreases in alcohol consumption than patients in the control group. Similar findings were demonstrated in an inpatient setting, where hepatology evaluation of patients with alcohol use disorder increased both prescriptions for alcohol use disorder medication and receipt of important preventive hepatology care.20
In our primary care practices, we have found that discussing liver disease screening with patients engaging in heavy alcohol use, regardless of the result of the screening, can lead to fruitful discussions about the health risks of their drinking.
A SIMPLE WAY TO INTEGRATE SCREENING INTO PRIMARY CARE
Primary care guidelines from the US Preventive Services Task Force21 recommend screening patients for heavy alcohol use but leave subsequent counseling and management up to clinicians. Among all of the major primary care, psychiatry, and addiction medicine professional organizations, including the US Preventive Services Task Force, American Academy of Family Physicians, US Department of Veterans Affairs, American Society of Addiction Medicine, and National Institute on Alcohol Abuse and Alcoholism, only the American Psychiatric Association mentions liver disease screening in their guidelines.22
Therefore, we propose the following pathway to screen for heavy alcohol use and liver disease (Figure 1), which can be integrated into existing primary care workflows around alcohol use.
Proposed algorithm for liver disease screening in the primary care setting.
Identify heavy alcohol use
The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool can be used to identify patients who drink heavily. AUDIT-C is a 3-question screening tool that can be easily implemented into primary care team workflows (Table 2).23 A score of 3 or higher in women or 4 or higher in men is positive for heavy drinking.
Alcohol Use Disorders Identification Test-Consumption
A phosphatidylethanol blood test, where available, can quantify alcohol use over the previous month and has demonstrated great promise as an objective measure of alcohol consumption.13 Values are typically divided into the following 3 categories:24
Less than 20 ng/mL indicates abstinence or very light alcohol use
20 to 199 ng/mL indicates moderate to significant alcohol use
Greater than 200 ng/mL indicates heavy alcohol use.
Then screen for liver disease
Based on assessment results, at-risk patients should be screened for liver disease with the fibrosis-4 index (a fibrosis risk index derived from basic laboratory tests) and liver ultrasonography. We recommend both because the complementary roles of these diagnostic tests increase the sensitivity of this screening strategy: a normal fibrosis-4 index result makes advanced liver fibrosis highly unlikely,1 and liver ultrasonography can detect hepatic steatosis.25 Combined, these 2 tests can determine the presence and severity of alcohol-related liver disease.
The fibrosis-4 index was initially developed for patients with viral hepatitis and human immunodeficiency virus coinfection, and low scores (< 1.3 in patients 65 years or younger) are associated with a low likelihood of liver-related outcomes.26 For this reason, expert consensus recommends that the fibrosis-4 index be used to risk stratify patients with alcohol-related liver disease.27
Patients with possible liver fibrosis should undergo evaluation with FibroScan, a noninvasive ultrasound-based test that uses vibrations to measure liver scarring or fibrosis, to confirm the diagnosis of cirrhosis and receive more intensive consideration of pharmacotherapy for alcohol use, referral to an addiction medicine specialist, and consultation with hepatology. Patients without concerning liver findings should still be counseled about the adverse effects of alcohol on other organ systems and offered pharmacotherapy for alcohol use, and should continue to be monitored because they could develop liver disease in the future.
POSSIBLE IMPLEMENTATION CHALLENGES
The recommendation to screen for liver disease in primary care has limitations. First, there is limited evidence that liver disease screening improves patient outcomes. While some randomized data exist, the impact of screening on mortality, the gold-standard outcome for screening trials, has not been evaluated. The European LIVERAIM consortium (liveraim.eu) will address this gap by investigating how liver fibrosis screening affects hospitalization and mortality in a randomized controlled trial of 100,000 participants. This is an important first-of-its-kind study that extends from 2024 to 2030. We are in the early days of evaluating liver disease screening, but evidence from other diseases (eg, lung cancer) shows that screening impacts health behaviors favorably.28
Another limitation to our recommendation is primary care capacity. Primary care clinicians already have many competing priorities and limited time with patients. The clear screening workflow we provide in Figure 1 aims to make incorporating liver disease screening into practice more feasible, and creative uses of technology could potentially streamline workflows. For example, a clinical decision-making support tool in the electronic medical record could automatically calculate a fibrosis-4 index score with existing data in patients with a positive AUDIT-C result. A pilot of this approach would be a reasonable first step to evaluate feasibility.
It is worth noting that even if uptake of liver disease screening increased in primary care, there are many patients with heavy alcohol use or alcohol use disorder who do not consistently receive primary care. Patients with low socioeconomic status are less likely to receive liver disease screening and treatment29 and management of alcohol use disorder,14 so efforts targeted to this population are crucial.
Finally, the economics of liver disease screening in primary care remain uncertain. Widespread use of liver ultrasonography in patients who drink heavily would likely incur significant costs, and, importantly, the patient may bear the cost of this testing if it is not covered by medical insurance. Furthermore, advanced diagnostic devices, like FibroScan, are not yet universally available. On the other hand, a cost-effectiveness study found that alcohol-related liver fibrosis screening, regardless of the method used, may increase quality-adjusted life years at a relatively low cost.30 This finding suggests that the benefits of screening in primary care could justify the expense by improving patient outcomes.
OUR CLOSING ARGUMENT
Despite the challenges of screening, primary care clinicians remain on the front line of healthcare and are uniquely positioned to diagnose liver disease in its early stages. Screening for liver disease in appropriate patients may address the rising prevalence of cirrhosis and liver-related mortality by informing discussions with patients about heavy drinking, alcohol use disorder, and the risk of liver disease progression. While we await gold-standard evidence from randomized controlled trials, the data we already have suggest that screening for liver disease may be a helpful tool for primary care clinicians to consider when addressing heavy alcohol use with their patients.
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2026 The Cleveland Clinic Foundation. All Rights Reserved.
REFERENCES
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.