The British Society of Gastroenterology (BSG) has published new guidelines on the management of liver blood tests, updating their original guidelines from 2000. The guidelines summarise the range of tests that make up the typical panel of liver blood tests; the clinical situations where LFTs should be considered; each test’s role in assessing liver disease; the other medical conditions associated with abnormal LFT results; and clinical pathways for the management of abnormal tests, assessing non-alcohol-related fatty liver disease (NAFLD)and alcohol-related liver disease.
Key points for GPs
- GPs should consider liver blood tests where there are non-specific symptoms that point to liver disease such as fatigue, nausea or anorexia; there is evidence of chronic liver disease including symptoms or signs of cirrhosis; conditions associated with liver disease including autoimmune diseases and inflammatory bowel disease; hepatotoxic drugs are being prescribed; there is a family history of liver-related diseases such as haemochromatosis or Wilson’s disease.
- GPs should be more cautious about checking LFTs when there are vague symptoms that do not point to liver disease (or other conditions where the LFT panel is relevant such as bone disease). In these circumstances LFT abnormalities are common and their clinical significance may be unclear.
- In alcohol misuse, standard liver blood tests are not effective in either confirming or excluding liver disease. NICE guidance is to screen for liver disease using transient elastography (proprietary name fibroscan) in men who persistently drink >50 units/week and women who drink >35 units/week (NICE cirrhosis guidance 2016).
- Most patients with chronic viral hepatitis are symptom-free, and many are unaware of their diagnosis. Hepatitis B and/or C tests are recommended when there are risk factors including being brought up in a high prevalence country; a history of injecting drug use; and close contact with an infected person
- NAFLD may be suspected when fatty liver is found on ultrasound scan. Other causes of fatty change, including alcohol misuse and viral hepatitis, should be excluded. In NAFLD the development of fibrosis can be assessed using simple algorithm-based scoring systems such as the FIB-4 test and NAFLD fibrosis score, or through the proprietary ELF blood test (NICE NAFLD guidance 2016).
- Abnormal liver tests should be followed up with full history and examination and further investigations as needed, focusing on patterns of abnormality such as hepatitic pattern; cholestatic pattern; isolated raised bilirubin; abnormalities of liver synthetic function; and red-flag patterns (synthetic failure, suspected malignancy and marked cholestasis)
The guidance recommends assessment pathways that are not currently part of routine general practice (FIB-4 test and NAFLD fibrosis score), though it would be a relatively easy task to embed these within primary care data systems in the same way that cardiac risk scores have been. Other recommended assessments are not currently available to GPs in many areas, such as ELF testing and transient elastography.
Dr Jez Thompson, a GP in Bradford and Leeds and the British Liver Trust/RCGP clinical champion for liver disease, said: ‘Liver disease is the only major cause of death that has a rising incidence. Primary care has a major role in identifying risk factors for liver disease and early liver disease, and in providing interventions to address the rising death rate from liver disease.’
Newsome PN, Cramb R, Davison SM, et al Guidelines on the management of abnormal liver blood tests Gut Published Online First: 09 November 2017. doi: 10.1136/gutjnl-2017-314924
Notes to Editors
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The British Society of Gastroenterology is an organisation focused on the promotion of gastroenterology within the United Kingdom. It has over three thousand members drawn from the ranks of physicians, surgeons, pathologists, radiologists, scientists, nurses, dietitians, and others interested in the field.
Founded in 1937 it has grown from a club to be a major force in British medicine, with representation within the British Royal Colleges and consequently the Department of Health and Government. Internationally it is represented at World and European level.