Signs and Symptoms

• Moderately 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). 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
• 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

• Symptomatic patients with overt jaundice - bilirubin above 50 - refer via fast track jaundice clinic pathway, see Fast-track Jaundice Clinical Referral Guideline
• 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
• ALT over 10 times upper normal limit (ULN) - Please telephone on-call Hepatologist at Derriford Hospital for advice

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)
• AMA

Within 5 years

• Ferritin
• Transferrin Saturation
• Hepatitis B surface antigen
• Hepatitis C antibody

Ultrasound scan of liver, biliary tree and pancreas

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

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

• All of the investigations as per ICE and a liver ultrasound results must be included
• The management must have followed the above pathway

Without these, the referral will be returned

With them, stratification will be possible through Rapid Referral Review (RRR) by the Hepatology team who will then manage appropriately

Referral Instructions

• Refer using the e-Referral Service:
  • Specialty: GI & Liver (Medicine and Surgery)
  • Clinic type: Hepatology
  • Service: DRSS-WC-Hepatology (PCT) (not for patient attendance)-Devon ICB-15N

Referral Forms

DRSS Referral Form

Patient Information

Patient.co.uk – Liver Function Tests patient leaflet

Evidence

British Society of Gastroenterology

British Liver Trust web site

Pathway Group

This pathway has been signed off on behalf of the NHS Devon.

David Sheridan - Consultant Hepatologist

Publication date: 23 May 2016