Liver disease

Abnormal Liver Blood Tests

Use the following pathway to initially guide investigation of patients with abnormal LBTs (updated 5.1.24):

• Abnormal Liver Blood Test Algorithm (BNSSG)

This pathway reflects the British Society of Gastroenterlology guidelines (1) and the British Medical Ultrasound Society guidelines (2).

Please review Red Flags and consider 2WW or Urgent Hepatology referral (see Red Flag section below). If there are no Red Flags then please use the appropriate pathway.

Please also consider use of Hepatology Advice and Guidance which is available via e-RS.

*Please note the following changes (December 2023):

• Requests for abdominal USS with need to meet certain before being accepted (from 1.1.24 - see Ultrasound section below)
• The term LBT (liver blood test) has replaced LFT.
• The term NAFLD is being phased out and will be replaced with MASLD (metabolic associated steatohepatitis liver disease).
• The MASLD liver pathway is currently being reviewed and will be updated in early 2024.

Alkaline Phosphatase (ALP)

ALP is an enzyme produced mainly by cells lining bile ducts but is also in bone and other organs. ALP can be elevated to a variety of causes. If ALP is raised and gamma-glutamyl transferase (GGT) is also raised then a liver cause is more likely (see abnormal liver blood test algorithm above). If GGT is normal then consider other causes - see the Alkaline Phosophatase page for details.

Alanine Aminotransferase (ALT)

ALT is a protein that resides in cells and is mainly specific to the liver. When raised it is an indicator of hepatocellular damage (3). It can be elevated transiently due to a variety of causes including drugs, inter-current illness, comorbidity, history or travel, insect bites, muscle injury. If a self -limiting explanatory cause is likely then it is recommened that blood tests should be repeated before proceeding to USS. If a transient cause is less likely then proceed to investigation as advised by the abnormal liver blood test algorithm above.

Aspartate Aminotransferase (AST) is another protein that is found in liver cells but is less specific than ALT and is not routinely performed in BNSSG labs (unless specifically requested)..

Chronic Liver Disease

Remember: Normal LBTs do not rule out liver disease.

If you suspect that a patient has chronic liver disease or has risk factors please use local pathways that have been developed with support of local hepatologists to guide GPs on how to investigate and manage patients and when to refer:

Alcohol Related Liver Disease Pathway

• This pathway should be considered for all patients drinking over 14 units of alcohol per week.
• Patients may have normal LBTs but still be at risk.
• Please follow the Abnormal Liver Blood Test Algorithm (BNSSG) simultaneously if liver blood tests are abnormal.
• Do not use this pathway if ALT > 300.

Non-Alcoholic Fatty Liver Disease Diagnostic Pathway (due to be updated in early 2024 and will be renamed the MASLD Diagnostic Pathway)

• This pathway should be used once significant alcohol use has been excluded (intermediate or high risk group as per the alcohol related liver disease pathway) and who may be at risk of NAFLD (obesity, diabetes, hypertension, HDL <1.0, triglycerides >1.7).
• Remember normal LBTs do not rule out liver disease.
• Please follow the Abnormal Liver Blood Test Algorithm (BNSSG) simultaneously if liver blood tests are abnormal.
• Remember to do a FIB-4 (and ELF test) if NILS is otherwise normal so that fibrosis can be estimated and appropriate follow up or referral made - see pathway.

Further advice on investigations:

NILS (Non-Invasive Liver Screen) - see NAFLD pathway above for details. The list of bloods is also available as a profile on ICE. This was updated in January 2023 after discussion with local hepatologists and Hep E serology has been removed. FIB-4 is not part of initial NILS but should be requested as a second line test if NILS is negative. It can be requested at the same time if metabolic syndrome risk factors suggest NAFLD is likely but should only be interpreted in context of otherwise normal NILS - see below.

Fibrosis-4 (FIB-4) is a calculation using age, AST*, ALT, platelet count. This  is not listed in the NILS profile on ICE as it is second line test, but can be requested at the same time if metabolic risk factors or requested if NILS is otherwise negative. It  can  be found on ICE as follows:  NBT - use the search function. UHBW - use the NAFLD pathway button on the Profiles tab.

*AST - aspartate aminotransferase - is not part of the standard NILS and is done automatically as part of FIB-4 test when then is chosen on ICE.

Enhanced Liver Fibrosis (ELF) test is a more specific marker of fibrosis in NAFLD and should be requested following an equivocal FIB-4 result (see pathway).  GPs can request this on ICE as follows: NBT - use the search function. UHBW - use the NAFLD pathway button on the Profiles tab.

AUDIT - screening tool for alcohol misuse/ dependence (Patient.co.uk)

Please also note the following advice:

• Statins and LBT checks - UKMi and BNSSG formulary - lipid (statin) guidance) still suggest LBTs should be repeated at 3 months and 12 months. Local hepatologists and BSG guidelines advise that statin induce liver disease is rare.

• All ICE panels should be the same for requesting a Non Invasive Liver Screen (NILS) across BNSSG.

• PRELUDE 1 Study - Referrals for patients on the PRELUDE 1 study should be sent via the study pathway (there is a referral form in EMIS and this should be sent via email to: MedicalResearchTeam@uhbw.nhs.uk

The BNSSG Referral Service will triage referrals to secondary care against these pathways and may return referrals where management in primary care is considered appropriate.

Patient information can be found on the British Liver Trust website.

Ultrasound and Fibroscans

Liver Ultrasound

Abdominal Ultrasound can be requested on ICE after considering the following:

From 1.1.24 requests that only state abnormal LFT / LBT will be returned with a request for additional information. The referral should state that a transient or alternative cause has been excluded. Where there is a high index of clinical suspicion that it is a transient finding, the blood tests should be rechecked initially, and only investigated if they remain abnormal. 

In addtion:

• Abdominal ultrasound for abnormal LBTs should be considered only after reviewing previous results, past medical history, and current medical condition.
• Where there is an explanatory cause (e.g. drugs, inter-current illness, comorbidity, travel, insect bites, muscle injury) repeat blood tests are advocated in the first instance. A single episode of mild or moderate elevation of a single enzyme in isolation, does not always justify an ultrasound scan.
• When alternative or transient causes have been excluded and LBT’s are persistently raised, ultrasound is justified.

This reflects British Medical Ultrasound Society guidance (May 2022) - Justification of Referrals in Primary Care | BMUS.

Other ultrasound advice:

• Urgent ultrasound - should be requested if there is abnormal LBT plus raised bilirubin or abdominal pain or jaundice (obstruction or significant disease likely – also consider Red Flags below.
• Alkaline Phosphotase - if there is an isolated rise in Alk Phos please confirm that it is of liver origin before proceeding with further investigation (i.e., doing either GGT or isoenzymes to exclude a bony source). If it is of liver origin, ultrasound is indicated to evaluate the biliary system.
• GGT - isolated rises in GGT do not require further investigation and should not trigger a request for Ultrasound.)

Fibroscan 

Fibroscan is scan that can assess liver stiffness and pick up fibrosis or cirrhosis. This can be requested directly via eRS (not ICE) for patients who are considered high risk as part of the Alcohol Related Liver Disease Pathway (see details in link to pathway above).

When making a referral please indicate clearly that this is what is being requested and indications for a direct scan. Depending on the result of the scan patients will either be referred automatically to the appropriate hepatology clinic (>16kPa indicating  possible cirrhosis) or returned to the GP for management in primary care. Therefore if the result of the fibroscan is less than 16kPa but the GP feels a hepatology referral is still required then a new referral to hepatology via eRS should be submitted.

Red Flags

Acute Liver Failure

If Acute Liver Failure is suspected then discuss with on call hepatology team or arrange admission for same day assessment in secondary care. See CKS - Jaundice in adults- Who should I admit?

Suspected Malignancy

See the Suspected Pancreatic Cancer Pathway for details of red flags and how to refer.

Patients with a history of jaundice, weight loss and signs of malignancy are at high risk of malignancy and should be referred via 2WW for suspected cancer. An USS on the next working day should also be requested.

Other Urgent Hepatology Referrals

NBT: There is a NBT Urgent Hepatology Service via eRS for patients who meet their referral criteria which include decompensated cirrhosis, ALT over 300, bilirubin over 100.

UHB:  UHB hepatology will also see patients urgently if indicated. Refer via eRS marked urgent.

Advanced Liver Disease

The hepatologists and palliative care team at UHB have produced guidelines on Symptom Control in Adults with Advanced Liver Disease.

This covers management of end stage complications of liver disease (Child Pugh B or C cirrhosis) such as pain, nausea, vomiting, encephalopathy, itching, ascites.

Local hospices can also give advice and support on End of Life care.

Referrals

Suspected Cancer

In patients with red flags consider 2WW Referral for suspected pancreatic cancer

Viral Hepatitis

If viral serology is positive for hepatitis then refer to Hepatology via eRS - see the Viral Hepatitis section for further information.

Fibroscan

If fibroscan is indicated then this can be requested in the following ways: 

• NBT - refer to the NBT Hepatology Fibroscan Clinic via eRS (this direct service is for patients with alcohol misuse only).
• UHB - refer to Hepatology Clinic via eRS explicitly requesting fibroscan

Hepatology Clinics (non-viral)

If Hepatology (non-viral) referral is indicated as directed by the pathways above, then please refer via eRS. Please make sure all components of a NILS have been completed prior to referral (including USS liver) and fibrosis test (fibroscan or ELF) if indicated.

For UHB you can use the optional UHB Hepatology Referral Form.

Urgent Hepatology Clinics

NBT: The  NBT Urgent Hepatology Service is for patients who meet their referral criteria

UHB: Mark referral urgent (BNSSG  Referral Service has been reassured that letters are triaged by the hepatologists and patients seen appropriately).

Resources

(1) British Society of Gastroenterology Guidelines

(2) British Medical Ultrasound Society guidelines- Justification of Referrals in Primary Care.

(3) Abnormal Liver Function Tests | Doctor | Patient

Alcohol Services:

• Bristol ROADS - link to local referral details for alcohol support and detox.
• North Somerset Drug & Alcohol Service - Addaction
• South Gloucestershire Drug & Alcohol Service - a link to the service's website.

FRAMES - advice on giving brief alcohol intervention (CKS)

AUDIT - screening tool for alcohol misuse/ dependence (Patient.co.uk)

Drinkaware - link to advice and leaflets for patients and health professionals.

Patient Information

Fatty Liver Disease - Patient.co.uk

Abnormal Liver Function Tests - Patient.co.uk

British Liver Trust has downloadable leaflets on the following:

• LFTS Explained
• Alcohol & Liver Disease
• Diet & Liver Disease

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.