The AASLD formed the Choosing Wisely Working Group in December 2013 to develop a list of recommendations. Members were selected from the AASLD Practice Guidelines Committee to broadly represent a variety of practice organizations and subspecialty expertise within the field of hepatology, and hepatologists experienced in evidence-based medical methodology were included. The working group solicited suggestions from all AASLD members to consider including a list of recommendations for tests or treatments that physicians and patients might ask for. A total of 10 recommendations were identified based on the working group’s vote, as well as a literature review of supporting data. The working group then voted on the final top five recommendations. These recommendations ranked in the top five were submitted to the AASLD Management Committee and were approved. The order of the recommendations was determined by several factors, including the harm, benefit, and excessive resource use of the testing program. Professor Raphael B. Merriman of the United States, who was involved in the development of the recommendations, was invited to give further explanation of each of the five recommendations. The recommendations are as follows: Recommendation 1: Patients with small varices and no red sign compensated cirrhosis should not be routinely monitored using esophageal, gastric, or duodenoscopy, but should be given non-selective beta-blockers to prevent first variceal bleeding. Dr. Merriman: “The first recommendation is based on one of the AASLD practice guideline recommendations related to portal hypertension and variceal bleeding, which relates to small-vessel cirrhotic patients who have not yet had bleeding and do not have increased risk criteria for bleeding (i.e., Child-Pugh class A and no red sign of varices on endoscopic evaluation). patients with varicose veins. In these patients, beta-blockers can be applied. Beta-blockers are preferred in patients with cirrhosis who have moderate or large-vessel varices that have not yet bled and are not at the highest risk of bleeding (i.e., Child-Pugh class A, no red flags). The dose of beta-blocker should be adjusted to the maximum tolerated dose. In both cases, follow-up esophageal, gastric, and duodenoscopy is not necessary. This recommendation may reduce the need for unindicated upper gastrointestinal endoscopy.” Recommendation 2: Prophylactic treatment of hepatic encephalopathy should not be undertaken indefinitely after a single remission of hepatic encephalopathy with identifiable triggers. Dr. Merriman: “This one reflects a recommendation of the recently published practice guidelines for hepatic encephalopathy, which were developed jointly by the AASLD and the European Association for the Study of the Liver. Patients may have episodes of hepatic encephalopathy with triggers that can be identified and controlled, such as recurrent infection or variceal bleeding. Treatment of hepatic encephalopathy is not necessarily indefinite and can actually be stopped when the triggers can be clearly identified and well controlled. This is important because in the past, it has become common practice to continue prophylactic treatment indefinitely after initiating treatment for hepatic encephalopathy, but in practice there is little evidence to support this. Therefore, this recommendation is of great importance to reduce the unnecessary application of treatment to prevent recurrent hepatic encephalopathy.” Recommendation 3: Do not repeat HCV RNA level testing in addition to antiviral therapy. Dr. Merriman: “This is an important, timely and pertinent recommendation, especially as the field of hepatitis C treatment is being revolutionized with a plethora of new, potent antiviral drugs that could cure hepatitis C. Highly sensitive serum HCV RNA testing is very expensive and is indicated for the diagnosis of hepatitis C, but also as part of antiviral therapy, and can be performed at the start of treatment, during treatment, and after completion of treatment. Except in these cases, the benefit of testing HCV RNA levels is minimal and usually has no impact on clinical management or regression. This recommendation is particularly relevant to patients, who often have the misconception that HCV RNA is important and needs to be monitored closely, and that small changes in HCV RNA levels are meaningful and can affect their clinical regression. Therefore, this recommendation may prompt discussions between physicians and patients and may hopefully reduce the need for unnecessary viral testing.” Recommendation 4: Do not routinely perform CT or MRI for monitoring benign focal lesions of the liver unless there are clinical findings or significant changes in symptoms. Dr. Merriman: “Focal liver lesions detected by imaging are present in many patients, often incidentally, who have no underlying liver disease and whose lesions are determined to be benign. Patients who are clinically and imaging stable do not require repeat imaging because the likelihood of developing a malignant lesion is very low (with the exception of hepatocellular adenomas). Clinical stability means the absence of any new symptoms associated with those focal lesions of the liver. This recommendation stems from the general recognition that even after clinical and imaging stabilization of benign focal lesions has been demonstrated, there is still a need to repeat imaging indefinitely, and this recommendation provides guidance to support discontinuation of serial imaging in these patients. Because these lesions are often found incidentally and are commonly found in younger populations, the additional implication of this recommendation is that we can reduce and avoid unnecessary imaging and, in the case of CT scans, unnecessary radiation exposure in this patient population.” Recommendation 5: Do not routinely transfuse fresh frozen plasma (FFP) and platelets prior to laparotomy or endoscopic varicose vein ligation. Dr. Merriman: “This recommendation stems from the customary practice of attempting to correct coagulation disorders such as increased international normalized ratio (INR) or thrombocytopenia that are common in patients with cirrhosis when performing procedures such as puncture or endoscopic variceal ligation. Recently, it has been recognized that these routine tests of coagulation do not accurately reflect the risk of bleeding in patients with cirrhosis. In fact, bleeding complications related to these maneuvers are very rare. Therefore, we strongly encourage patients and their physicians to discuss whether patients with increased INR or thrombocytopenia undergoing these maneuvers have an indication for routine transfusion of FFP and/or platelets, and this recommendation has the potential to reduce unnecessary transfusions of limited and expensive blood product resources.”