Abnormal Liver Function Tests Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Asymptomatic patients over 16 years old with abnormal liver function tests.

Assessment

Signs and Symptoms

  • Raised isolated bilirubin (under 50umol/L) – commonly due to Gilbert's syndrome (or haemolysis) which occurs in 5% of the population, is benign and does not need referral. Check conjugated / unconjugated split to check the rise is unconjugated and exclude haemolysis (reticulocyte count, LDH, haptoglobins)
  • Cholestatic pattern – alkaline phosphatase (ALP) raised significantly more than alanine transaminase (ALT)and a raised bilirubin. Consider bone causes of raised ALP (e.g. Paget's), raised gamma-glutamyl transpeptidase (GGT) can help confirm a liver cause
  • Hepatitic pattern - raised ALT (and / or aspartate aminotransferase (AST), although ALP may also be raised

History and Examination

  • Drugs, including herbal remedies, anabolic steroids and IV drug users
  • Alcohol (see toolkit for AUDIT tool)
  • Recreational drug use
  • Features of metabolic syndrome (see toolkit)
  • Ethnicity
  • Foreign travel

Differential Diagnoses

  • Alcoholic liver disease – Indicators: history, raised mean corpuscular volume (MCV) and GGT, raised immunoglobulin A (IgA), fatty liver on ultrasound scanning, and the AST:ALT >2:1
  • Non-alcoholic fatty liver disease – Indicators: fatty liver on USS, negative liver screen, raised BMI or waist circumference, hypertension, impaired fasting glucose or type 2 diabetes, raised triglycerides, low high-density lipoproteins (HDL) cholesterol, raised IgA. LFT shows mainly isolated raised ALT
  • Chronic Viral Hepatitis – Indicators: risk behaviours, origin from endemic countries, blood transfusion, positive serological markers
  • Primary Biliary Cirrhosis – Indicators: raised ALP (cholestatic), positive anti-mitochondrial antibodies (AMA), raised IgM, history of auto immune (thyroid) disease, fatigue and or itch may be present
  • Primary Sclerosing Cholangitis – Indicators: raised ALP (cholestatic), history of inflammatory bowel disease
  • Auto-immune hepatitis – Indicators: positive antinuclear antibody (ANA) or smooth muscle antibodies (SMA), raised Immunoglobulin G (IgG)
  • Haemochromatosis – Indicators: raised ferritin and transferrin saturations, diabetes, joint pains
  • Wilson's disease request for copper and caeruloplasmin

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Symptomatic patients with overt jaundice - bilirubin above 50 also with weight loss - refer via fast track 2 ww upper GI pathway
  • Patients with upper abdominal pain and/ or weight loss - consider referral via 2ww upper GI pathway
  • Other signs of liver decompensation - ascites, encephalopathy, bleeding - for assessment either as an urgent admission via Medical Assessment Unit (AMU) or refer for urgent outpatient appointment in liver clinic
  • ALT over 10 times upper normal limit (ULN) – urgent referral to liver clinic

Investigations

Most recent

  • AST and ALT
  • ALP
  • Bilirubin (Bili)
  • Albumin (Alb)
  • GGT
  • Full Blood Count (FBC)

Within 1 year

  • IgA
  • IgG
  • Immunoglobulin M (IgM)
  • Antinuclear Antibody (ANA) }
  • Smooth Muscle (SMA) } Auto antibody screen
  • AMA }

Within 5 years

  • Ferritin
  • Transferrin Saturation
  • Hepatitis B surface antigen
  • Hepatitis C antibody
  • Ultrasound scan of liver, biliary tree and pancreas

Management

ALT 40-80

  • AUDIT C to stage alcohol risk
  • reduce alcohol intake - encourage abstinence
  • if BMI over 25 encourage weight loss
  • review recently started medications e.g. statins, antibiotics
  • assess viral hepatitis risk
  • re-check with AST in 3 months if suspected non-alcoholic fatty liver disease (NAFLD) or alcoholic liver disease

ALT over 80

  • As above but recheck in 4 weeks with AST

ALP over upper limit of normal

  • recheck in 4 weeks with GGT
  • if GGT is normal then check bone profile and phosphate to assess for a bone cause such as Pagets or vitamin D deficiency

Isolated raised GGT

  • alcohol- measure MCV and AST:ALT >2:1
  • drugs history - mainly anti-epileptics
  • uncontrolled Diabetes Mellitus (DM)- check HbA1c
  • obesity

When the liver enzymes are rechecked if:

  • ALT remains abnormal
  • ALP greater than the upper limit of normal with GGT greater than the upper limit of normal

Then perform:

  • Chronic liver disease screen (In Order Sets on ICE) including AST
  • Liver ultrasound scan

Referral

Referral Criteria

  • Refer via fast track 2 ww upper GI pathway
    • Symptomatic patients with overt jaundice - bilirubin above 50 also with weight loss
  • Consider referral 2 ww upper GI pathway
    • Patients with upper abdominal pain and/ or weight loss
  • Refer as urgent admission via Medical Assessment Unit (AMU) or for urgent outpatient appointment in liver clinic
    • Other signs of liver decompensation - ascites, encephalopathy, bleeding
  • Refer urgently to liver clinic
    • ALT over 10 times upper normal limit (ULN)

Referral Requirements

  • All referrals should include:
    • Results from investigations as per ICE (liver screen) and liver ultrasound
    • Evidence that the management identified in the pathway has been followed
  • Without this information the referral will be returned

Referral Instructions

  • e­Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training refer using eRS to Gastroenterology, Clinic: Liver
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 07.2017
  • Publication Date: 07.2017
  • Review Date: 07.2019
  • Ref No: GA3 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
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