Predominantly Raised ALP
Introduction
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Abnormal LFTs have often not been investigated adequately- Many patients present with end stage liver disease without a previous diagnosis of liver disease were noted to have previous abnormal liver tests.
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Mild rises should not be overlooked– the extent of liver blood test abnormality is not a guide to clinical significance (e.g. chronic Hep C with a lower ALT may be worse than acute Hep A with an ALT>1000).
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Patients should be considered for investigation irrespective on the abnormality- Do not overlook mild rises and consider patients for investigation if no obvious cause regardless of the duration or level of the abnormality.
- However, the majority of adults with abnormal LFTs will be identified to have metabolic associated steatotic liver disease (MASLD, previously known as non-alcoholic fatty liver disease or NAFLD) or alcohol-related liver disease (ARLD). Most simply require reinforcement of lifestyle advice and ongoing assessment in primary care.
Red flags
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Synthetic failure – jaundice, low albumin, ascites, prolonged INR, encephalopathy
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Features of malignancy –
- weight loss and marked cholestasis
- weight loss >60yrs with any of:diarrhoea, back pain, abdominal pain, nausea or vomiting, constipation, new onset diabetes
- Jaundice in patient >40years
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ALT >300 iu/l
- Dilatation of common bile duct on ultrasound or liver/gallbladder/pancreatic mass lesions
Key Features of Assessment
(In patients > 80 years old or with significant frailty use clinical to avoid unnecessary investigation)
In addition to usual assessment check for:
- Contributing conditions – diabetes, viral hepatitis, autoimmune disease, cancer, coeliac, haemochromatosis, IBD (risk of primary sclerosing cholangitis or autoimmune hepatitis)
- Excessive alcohol or recreational drug use
- Pregnancy
- Medications– esp. statins, anticonvulsants, antibiotics (particularly flucloxacillin, erythromycin, doxycycline or co-amoxiclav), paracetamol.
- Herbal treatments – black cohosh, weight loss/bodybuilding supplements, Chinese herbal medicines, green tea extract, turmeric.
Investigations
If GGT raised – liver origin. If ALP raised in isolation, consider bone origin.
Management
Follow flow chart as above plus in addition to usual management particularly review medications:
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Recent statins, antibiotics, NSAIDs; STOP any drugs known to be associated with drug-induced liver injury.
- If there is a temporal relationship between a new medication and LFT changes, consider drug-induced liver injury and discontinuation medication. Repeat LFTs in 1-3 months depending on clinical judgement.
Advice and Guidance
Please send advice and guidance requests via e-RS to: http://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/gastro/rcht_hepatology_advice_and_guidance
Referral
Acutely Unwell (e.g. sepsis, severe encephalopathy, severe ascites restricting movement and breathing, GI bleeding.) - Admit via Acute GP (Mon-Fri 8am-6pm, Sat-Sun 9am-6pm) or via the on-call Medical SpR outside of these hours.
Painful cholestasis or painful jaundice&sepsis– admit general surgery
Pregnant with abnormal LFTs: refer to Maternity Day Assessment unit via on-call O&G SpR
Suspected cancer – Fast trackUSC Upper GI Cancer
- >40 years old with jaundice
- Abnormal CT or ultrasound scan consistent with pancreatic, liver, or gallbladder cancer
- Patient older than 60 years with weight loss and any of: diarrhoea, back pain, abdominal pain, nausea or vomiting, constipation, new onset diabetes
Weight loss and Cholestasis– Urgent referral (hepatology will triage and see ASAP due to risk of malignancy)
Jaundiced patients:
- Painless jaundice - Arrange FBC, LFTs, INR and USS and refer urgently to the Rapid Access Jaundice clinic.
Symptomatic liver disease (ascites/encephalopathy):
Urgent Hepatology referral or urgent admission (particularly if unwell or gastrointestinal bleeding)
Primary biliary cholangitis (PBC)
- ↑ALP + positive antimitochondrial antibody (AMA) - refer urgent hepatology
Primary sclerosing cholangitis (PSC)
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IBD + abnormal LFTS - refer to hepatology
ALT>300 and asymptomatic:(if symptomatic refer depending on symptoms)
- Refer hepatology A&G
For East-facing Cornwall practices. Please see South & West Devon DRSS Referral Guidelines
Supporting Information
For professionals:
- Gut – Guidelines on the Management of Abnormal Liver Blood Tests
- Health Technology Assessment – Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): A Prospective Cohort Study
- RCGP e-learning abnormal LFTS
For patients:
- Patient UK – Abnormal Liver Function Tests
Page Review Information
Review date |
April 2024 |
Next review date |
April 2026 |
Speciality Lead GP |
Dr Madeleine Attridge (Hepatology lead GP) |
Contributors
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Dr Hyder Hussaini (Consultant Hepatologist RCHT) Anna Barton (Principal Clinical Biochemist)
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