Updated Guidelines on the management of abnormal liver blood tests
The overall number of deaths from liver disease have been increasing dramatically, with a 400% increase in the standardized mortality rate over the period 1970–2010. The rising burden of liver disease is mainly a reflection of the three the most common causes: alcohol-related liver disease, non-alcoholic fatty liver disease, and viral hepatitis. Liver blood or function tests (LFTs) are required to be conducted ever more frequently in both primary and secondary care in an attempt to exclude liver disease, for the monitoring of potential adverse effects of drugs on the liver such as statins, and for the investigation of the generally unwell patient.Alongside there is a need for management of abnormal liver blood tests.
These updated guidelines on the management of abnormal liver blood tests have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines, which this document supersedes, were written in 2000 and have undergone extensive revision by members of the Guidelines Development Group (GDG). These guidelines deal specifically with the management of abnormal liver blood tests in children and adults in both primary and secondary care and are not designed to deal with the management of the underlying liver disease.
Recommendation 1: Initial investigation for potential liver disease should include bilirubin, albumin, alanine aminotransferase (ALT), alkaline phosphatase (ALP) and γ-glutamyltransferase (GGT), together with a full blood count if not already performed within the previous 12 months. (level 2b, grade B)
Research Recommendation 1: Further evidence is required to establish the cost-effectiveness of case finding for non-alcoholic fatty liver disease (NAFLD) in high-risk groups before it can be recommended. (level 5, grade D)
Recommendation 2: Abnormal liver blood test results should only be interpreted after review of the previous results, past medical history and current medical condition. (level 5, grade D)
Recommendation 3: The extent of liver blood test abnormality is not necessarily a guide to clinical significance. This is determined by the specific analyte which is abnormal (outside the reference range) and the clinical context. (level 5, grade D)
Recommendation 4: Patients with abnormal liver blood tests should be considered for investigation with a liver aetiology screen irrespective of level and duration of abnormality. Abnormal refers to an analyte which is outside the laboratory reference range (level 2b, grade B)
Recommendation 5: In adults a standard liver aetiology screen should include abdominal ultrasound scan (USS), hepatitis B surface antigen, hepatitis C antibody (with follow-on polymerase chain reaction (PCR) if positive), anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin and transferrin saturation. (level 2b, grade C)
Recommendation 6: In children, ferritin and transferrin saturation may not be indicated, but autoantibody panel should include anti-liver kidney microsomal antibody and coeliac antibodies. Alpha-1-antitrypsin level and caeruloplasmin (age >3 years) should be included, and abnormalities discussed with an appropriate inherited metabolic disease specialist. (level 2b, grade C)
- Recommendation 7: Adults with NAFLD should undergo risk stratification to determine the extent of their liver fibrosis
First-line testing should use either fibrosis-4 (FIB-4) or NAFLD Fibrosis Score (NFS) – see table 3 (level 2b, grade B). Calculation facilities for FIB-4 and NFS should be incorporated in all primary care computer systems. (level 5, grade D)
Second-line testing requires a quantitative assessment of fibrosis with tests such as serum enhanced liver fibrosis (ELF) measurements or Fibroscan/acoustic radiation force impulse (ARFI) elastography. (level 2b, grade B)
We recommend that hepatologist at a local level champion this idea and discuss it with commissioners of health to deal with the burden of liver disease in their area.
Recommendation 8: Consider referral to alcohol services for all adults with alcohol-related liver disease (ARLD) with evidence of alcohol dependency as defined by an AUDIT score of >19. (level 3b, grade C)
Recommendation 9: Harmful drinkers should undergo risk stratification with clinical assessment and Fibroscan/ARFI elastography. Adults should be referred to secondary care if there is evidence of advanced liver disease (features of cirrhosis or portal hypertension on imaging or from blood tests) and/or Fibroscan reading is >16 kPa (if available). (level 2b, grade B)
Research Recommendation 2: Further evidence is required to establish the most cost-effective approach to identify patients with ARLD and NAFLD at risk of having advanced liver fibrosis.
Recommendation 10: Adults with abnormal liver blood tests, even with a negative extended liver aetiology screen and no risk factors for NAFLD, should be referred/discussed to a gastroenterologist with an interest in liver disease/hepatologist for further evaluation (level 4, grade C).