Clinical

Diagnosis

Jaundice and Abnormal Liver Function Tests

Background

  • The incidence of liver disease is rising throughout the world and now accounts for 1.5% of deaths in the UK www.statistics.gov.uk
  • In parallel there has been a year on year rise in the number of liver function tests (LFT) carried out in UK primary care practices. Liver functions tests are misleadingly named measureing two separate things liver injury (liver enzyme elevations) which is commonly abnormal and true liver function which is less common and usually represents clinically obvious severe disease.
  • Primary care practitioners (PCPs) are thus commonly faced with the scenario of abnormal liver enzymes in patients in whom there are no clinical risks, signs or symptoms of liver disease. In the general population the prevalence of abnormal LFTs ranges between 6.3 and 20.9% depending on the definition, and is often an incidental finding.
  • The natural history of most liver diseases is a long one, many decades, and abnormalities of liver enzymes will not lead to serious liver disease in the short or medium term, and in many cases not even in the long term.
  • Markers of hepatic fibrosis are available which are validated in the detection of advanced liver disease (cirrhosis) or its exclusion although there is little evidence to their utility in primary care settings.
  • Other patients will present clinically with symptoms of liver failure such as jaundice which can reflect a wide range of pathology from drug reactions through to acute viral hepatitis, alcohol and malignancy.

Patient View

  • There is a need to increase understanding of liver disease and its many causes, to improve patient outcomes and reduce the stigma many patients experience. Currently there is a perception that all liver disease is due to alcohol.

Current Practice

  • Prior to the development of end-stage liver disease patients are usually asymptomatic.
  • The decision of whom to refer to secondary care with abnormal liver enzymes and when is often arbitary and has no relationship to the risk of serious disease being present.
  • There is therefore a wide variation in thresholds for referral to secondary care.

Recommended Practice and Opportunities for Integrated Working

  • Our principal recommendation is the establishment of local pathways for the investigation and referral of
    • Patients with abnormal LFTs. These could usefully be based on the established national map of medicine and should incorporate a measure of hepatic fibrosis or algorithms to predict it..
    • Acute jaundice: These could usefully be based on Hot clinics for such patients with short referral waits. The current 2ww system for cancer has jaundice as one of the triggering symptoms. I would suggest it would be better to suggest this is used rather than a separate system as GPs will not distinguish cancer v not cancer. What about: Jaundice is a symptoms suggesting serious disease and is a trigger for 2ww referral. This system should be developed and adapted to ensure every patients with jaundice due to cancer or other causes is seen and assessed at a single visit.
  • National acute liver failure standards: These are monitored on a quarterly basis by NHSBT and demonstrate patient and graft survival for patients transplanted for acute liver failure. Not sure this helps at all, it rare and being monitored and if jaundice goes via 2ww will be picked up anyway . I would omit this.
  • High risk groups for hepatitis B and C infection are readily identifiable. Models exist for community based services for detection and local management of hepatitis C infection in people attending substance misuse services or in prisons and these should become the standard model of care nationally. Ethnic minority groups at high risk of hepatitis B and C can readily be identified from general practice records and appropriately assessed in a community setting.

Desirable changes in practice include:

  • Patient held record. This would contain, on a single page or equivalent, enough practical information about history, treatment, adverse effects, monitoring, responsibilities and key dates (eg liver biopsy, surveillance endoscopy) to enable decisions to be taken instantly. The record could be electronic, on paper or a paper copy of an e-record
  • Shared records: Ultimately a patient held record automatically extracted from General Practice and (if possible) hospital records and accessible and modifiable in real time by the GP, the hospital and by the patient would be a logical and desirable extension of the patient held record which should be seen as an imperfect compromise. Commissioners should challenge IT departments to establish such a system.

Opportunities for Savings

  • There is major potential for improving care and also saving money. Reduce unnecessary referrals by appropriate triaging and investigation in primary care.
  • Prevention of progression to end stage disease and reduced complications of liver disease, reduced hospitalisation, reduced incidence of HCC and reduced requirement liver transplantation

Quality Indicators (Outcomes)

Some process metrics are highly likely to impact on outcomes:

  • Presence of a locally agreed investigation and referral pathway
  • Providers participate in national audits
  • Adherence to locally agreed investigation and referral pathway

Outcome measures

  • Adherence to locally agreed investigation and referral pathway
  • Proportion of patients attending secondary care who have significant liver disease
  • Reduction in complications of liver diseae by identification and therapy of cirrhosis and treatable liver disease such as hepatitis B and C

Social Policy & Understanding

  • By themselves ALFTs do not constitute a major economic or social impact, although they are independent risk factors for poor outcome.
  • The commonest cause of asymptomatic ALFTs is non alcoholic fatty liver disease (NAFLD). This reflects the major public health issues of obesity and type 2 diabetes and can be a surrogate marker for cardiovascular disease.
  • Alcoholic liver disease remains a major public heath issue.
  • ALFTs may further represent a major burden to the NHS by way of investigations.

References