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Management of abnormal liver blood tests

(Referral pathways adapted from BSG guidelines1)

 

KEY POINTS1:

  • Abnormal LFTs have often not been investigated adequately- 50% of patients presenting with end stage liver disease without a previous diagnosis of liver disease were noted to have previous abnormal liver tests
  • Mild rises should not be overlooked – The extent of the liver blood test abnormality is not necessarily a guide to clinical significance (e.g. chronic Hep C with a lower ALT may be more significant than acute Hep A with an ALT over 1000)
  • Patients should be considered for investigation irrespective of the duration of the abnormality –Single unexplained abnormal liver tests (e.g. by drugs, infection etc.) warrant further investigation in the absence of a cause.It is important to note that liver tests may appear to return to normal but the underlying cause will still be there (e.g. fatty liver).
  • Common causes of abnormal liver blood tests

- Alcohol related liver disease (ARLD)

- Non alcohol related liver disease (NAFLD)

- Chronic viral hepatitis (HBV/HCV)

- Medication

 

 

RED FLAGS: (urgent referral/2ww HBP) (admit if acutely unwell)

  • Jaundice – Refer to jaundice clinic 
  • Low albumin/raised INR
  • Ascites
  • Encephalopathy
  • Weight Loss/marked cholestasis (refer 2ww HBP)

 

 


SPECIFIC POSTIVE LIVER AETIOLOGY SCREEN RESPONSES TO AID DIAGNOSTIC PATHWAY

  • NAFLD suspected – If USS shows fatty liver disease or raised AST:ALT ratio follow NAFLD guidelines

(Note patients with a raised ALT/GGT who are obese may still have NAFLD despite a normal USS)

Raised ALT/AST ratio is only relevant in fatty liver disease (ie ignore if normal BMI)
 

  • RAISED BILIRUBIN:

No haemolysis, mostly unconjugated bilirubin (>70%) = Gilbert’s (no referral needed)

Haemolysis +unconj. Bilirubin = Refer haematology

Mostly conjugated bilirubin (>50%) = ?drugs, ?Dubin-Johnson Rotor syndrome.
 

  • JAUNDICE:

  - Check LFTs, FBC, INR, USS

  - Refer Rapid Access Jaundice Clinic

  • ALCOHOL RELATED LIVER DISEASE

- (Liver ultrasound not required) – see RMS alcoholic liver disease page

  • Hep B serology +ve – Refer hepatology with HIV/HCV serology
  • Hep C antibody +ve - Perform Hep C viral load & request Genotype
    • HIV /HBV serology
    • If HCV PCR positive – refer hepatology
    • If negative – repeat 3m later and if still negative reassure patient infection has cleared, no need to refer
       
  •  Positive anti-mitochondrial antibody – refer Hepatology
  •  Anti-smooth muscle antibody or anti-nuclear antibody positive with raised IgG - refer to Hepatology (A&G if antibody positive with normal IgG)
  •  RAISED FERRITIN:
    • Exclude common causes – alcoholism, inflammation, metabolic syndrome/fatty liver, cell necrosis, malignancy.
    • If not explained by common causes and normal FBC – request ‘Haemochromatosis: Investigation’ on ICE (contains: LFT, Ferritin, Iron Saturation and HFE Gene).
    • see Genetic Haemochromatosis Clinical Guideline
    • HFE gene +ve – refer hepatology
    • No HFE gene - hepatology A&G.
    • (Genetic haemochromatosis is a common condition, affecting around 1 in 150 people, characterised by iron overload. The majority of patients with genetic haemochromatosis are homozygotes for the C282Y polymorphism. Early treatment with venesection is effective in preventing irreversible complications and improving mortality.*consider iron loading anaemia if FBC abnormal.)

 

 

REFERENCES:

  • Guidelines on the management of abnormal liver blood tests. Newsome PN, et al. Gut 2017;0:1–14. doi:10.1136/gutjnl-2017-314924
  • Lilford RJ, Bentham L, Girling A, et al. Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study. Health Technol Assess 2013;17:1–307
  • Angulo P, Hui JM, Marchesini G et al. The NAFLD fibrosis score A noninvasive system that identifies liver fibrosis in patients with NAFLD Hepatology 2007;45(4):846-854 doi:10.1002/hep.21496
  • Sterling RK, Lissen E, Clumeck N, et. al. Development of a simple noninvasive index to predict significant fibrosis patients with HIV/HCV co-infection. Hepatology 2006;43:1317-1325.
  • McPherson S, Stewart SF, Henderson E et al. Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non-alcoholic fatty liver disease. Gut 2010;59:1265–9 doi:10.1136/gut.2010.216077

 

 

Review Date                      10/03/2022

Next Review Date              10/03/2023

GP Lead reviewer              Dr Madeleine Attridge Gastroenterology Lead RMS

Contributors                       Dr Hyder Hussaini Consultant Gastroenterologist RCHT

                                           Anna Barton Principal Biochemist RCHT

                                           Dr Joseph Taylor, GP