LFTs: an update A MacGilchrist PLIG meeting 31st January 2019

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Bathsheba McCormick
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1 LFTs: an update A MacGilchrist PLIG meeting 31 st January 2019

1-2% develop significant liver disease The case for investigation above data based on

2 LFTs: what are we trying to achieve? (1) The case against investigation abnormal LFTs in up to 21% of the population only 1-2% develop significant liver disease The case for investigation above data based on short term follow up (3 years) liver disease is second common cause of death under 65 yrs presents at advanced stage with high mortality

3 LFTs: what are we trying to achieve? (2) Diagnosis ALD NAFLD Chronic viral hepatitis Hepatitis B Hepatitis C Haemochromatosis Autoimmune liver disease PBC AIH Biliary disease Cancer Severity liver function bilirubin albumin INR fibrosis/cirrhosis 1 0 care: indirect ratios e.g. Fib4 (2 0 care: Fibroscan, hyaluronic acid)

4 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

5 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

6 Changes 1: Refer to Hepatology (rather than GI) all are directed to liver unit, RIE all undergo daily etriage use SCI gateway both for traditional clinic referral and as electronic helpline 40% of hepatology referrals do not result in liver appointment no waiting list for liver clinic

7 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

8 Changes 2: include transferrin saturation when measuring ferritin raised ferritin very common, only minority have iron overload, other explanations include alcohol XS ALD NAFLD inflammation BUT haemochromatosis is common, underdiagnosed and readily treated, so.. if raised ferritin ( > 300 ug/l) and TS (>50%), check HFE (haemochromatosis gene test)

9 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

10 Changes 3: restrict liver immunology screen + ANA < 1/80 common in normal population only request liver immunology screen if elevated ALT or ALP (i.e. not if isolated GGT) include immunoglobulins as well as liver autoantibodies (ANA, ASMA and AMA) in liver immunology screen ignore ANA < 1/80 if other AAs negative and IgG normal

11 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

12 Changes 4: stage fibrosis using FIB-4 rather than AST:ALT ratio indirect ratios AST: ALT ratio FIB-4 age, AST, ALT, platelets automated validated for NAFLD and Hepatitis C Others APRI (AST, platelets) NFS (age, BMI, AST, ALT, platelets, albumin, diabetes) AST > ALT: either fibrosis or ALD direct markers imaging: fibroscan, ARFI biomarkers: hyaluronic acid, ELF

13 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

14 Changes 5: to GGT or not to GGT? pre 2012: LFTs include GGT if RIE lab (1 0 and 2 0 care) LFTs do not include GGT if WGH lab (1 0 and 2 0 care) 2012-present: LFTs include GGT if 1 0 care LFTs do not include GGT if 2 0 care future (maybe!): LFTs will not include GGT in 1 0 care or 2 0 care BUT request GGT if diagnosing/assessing/investigating isolated raised ALP NAFLD T2DM (will be included in order data set) alcohol misuse cirrhosis Audit of LFTs in primary care in Edinburgh in one month raised GGT 4,999 raised GGT alone 3,238 GGT > % (349) had an USS of these 71% (248/349) abnormal 10.6% (37) cirrhosis

15 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

16 Changes 6: perform liver screen after single raised LFTs cost effective but apply common sense applies only to investigation of asymptomatic abnormal LFTs Changes 7: lower threshold for abnormal ALT What is an abnormal ALT? (currently > 50) men > 30 women > 19

17 Management of Asymptomatic Abnormal LFTs in Primary Care in Lothian Guideline summary December 2013 Asymptomatic abnormal ALT, GGT or ALP result Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart ALT > 70 ALT with an abnormal GGT/ALP (If isolated ALT check Hep B&C serology only) GGT >100 ALP >200 with an abnormal GGT (If ALP raised in isolation investigate for bone disease) (NB: If ALT/ALP/GGT persistently abnormal but below thresholds for investigation consider repeat LFTs in 1 year. If still abnormal use clinical judgment and consider patient assessment/ liver screen even if remains below thresholds) History Examination Liver screen including liver ultrasound Medication review If alcohol suspected, advise abstinence Refer to GI if any of the referral criteria* are met History Alcohol intake Drugs (prescribed, OTC, herbal remedies) Hepatitis risk factors (IVDA, sexual history, travel, ethnicity) Metabolic syndrome clues (T2DM, obesity, hypertension, hyperlipidaemia) Autoimmune disease clues (T1DM, thyroid disease, RA) Family history Examination BMI Spider naevi, Palmar erythema Palpable liver or spleen Liver Screen Abdominal Ultrasound FBC LFTs AST:ALT ratio Albumin, Caerulopasmin (if <55 years) Glucose Cholesterol Ferritin (check Transferrin sats if ferritin raised) INR Hepatitis serology HBsAg and anti-hcv Ab Immunology Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab Medication Review Review medications and consider discontinuing any causative drugs. If in doubt, discuss with GI/liver If the referral criteria have not been met then: The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes. At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care Consider a yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice *GI Referral Criteria Refer to GI if any of the following apply: Diagnostic tests suggest any cause other than alcohol or NAFLD Evidence of impaired liver function: bilirubin (not due to Gilberts syndrome) INR, albumin Evidence of advanced fibrosis/cirrhosis AST : ALT ratio > 1.0 Platelets < 150 Splenomegaly ALT persistently > 200 Diagnosis or management still uncertain Review date: December 2016

18 Changes 8: 1 0 care follow-up

19 ilfts 1

20 Tayside pilot in 6 GP practices: when GP request LFTs, asked if wants liver screen? If yes, adds BMI and alcohol history to request form auto analyser selects additional tests according to results uses algorithms to advise GP of outcome: 1. likely ALD without significant fibrosis 2. likely NALFD without significant fibrosis 3. likely ALD or NAFLD with significant fibrosis 4. possible other diagnosis (with or without fibrosis) 5. unclear 1 & 2 manage in primary care 3 & 4 refer to hepatology 5 GP review (?) ilfts 2 ilfts 3 Tayside pilot completed, role out in progress, limited uptake Pilots elsewhere delayed by technical problems SG and HBs remain interested, National lead appointed, planned further pilot in GGC Watch this space, but don t hold your breath!

LFTs: what are we trying to achieve? (3) explanation for abnormal LFTs?...... or opportunistic screening for liver disease? but are LFTs a good way to detect liver disease?

21 LFTs: what are we trying to achieve? (3) explanation for abnormal LFTs? or opportunistic screening for liver disease? but are LFTs a good way to detect liver disease? is a better starting point the at risk population? overweight diabetic XS alcohol is a better screening tool a fibrosis marker e.g. Fibroscan n = 79 26% abnormal Fibroscan 16% significant liver disease 8% cirrhosis

22 Offered Fibroscan to patients with XS alcohol and T2DM in selected GP practices in Nottingham

23 summary now continue to use RefHelp pathway to investigate LFTs. 2. include TS with ferritin 3. measure liver AAs and IgGs only if raised ALT or ALP 4. use SCI gateway referrals as liver helpline soon probable removal of GGT from initial LFTs 2. apply pathway to any asymptomatic LFTs 3. FIB-4 rather than AST:ALT ratio to assess liver fibrosis in the future ilfts 2. Fibroscan to screen for liver disease in at risk patients always... think why you are requesting LFTs!

2. Liver blood tests and what they mean p2 Acute and chronic liver screen

Hepatology referral pathways for GP 1 Scope For use within hepatology Contents 2. Liver blood tests and what they mean p2 Acute and chronic liver screen p2 Common reasons for hepatology referral 3. Raised