Abnormal Liver Function Tests Guidance

This guidance has been developed in collaboration with local specialists in Camden and Islington.
This is to assist GPs in decision making and is not intended to replace clinical judgment.
Consider doing LFTS
 if sx of liver/bile system disease
e.g. abdo pain/nausea/vomiting/jaundice GP Receives Abnormal LFTs:
 pt drinks excessively History and Examination with attention to Alcohol consumption, Metabolic Syndrome, BMI,
 pt taking medication that affects the liver Hepatotoxic Drugs & Risk factors for Viral Hepatitis
 pt has diabetes
 Obesity
 GGT – useful in cholestasis or monitoring Normal Bilirubin with Normal Bilirubin with NB urgent referral
changes in alcohol consumption Hepatitic LFTs Cholestatic LFTs if Hepatic or Biliary
(ALT>ALP) (ALP>ALT) Malignancy
Jaundice Isolated Raised suspected
Pattern (Bil>40) Bilirubin with other
Recognition Abnormal LFTs normal LFTs
ALT<300 IU/L
Repeat within one month to
ALT>300 IU/L
Most commonly due to Gilbert’s Repeat within one month confirm still elevated;
Urgent
syndrome (unconjugated with AST ,GGT, FBC to confirm still liver aetiology suggested by
Ultrasound
hyperbilirubinaemia - affects 5% of elevated elevated GGT
and/or
the population and is benign) (otherwise consider bone
Urgent 2 week
Consider HCV and HBV aetiology and check Vitamin D)
referral to
Less commonly due to haemolysis Seek telephone
secondary care
(Consider Reticulocyte count, LDH, If alcohol consumption >21U/Week advice and consider
or admission
haptoglobin) (14U/Week proposed) ♂ , >14U/ urgent tests
Week ♀ then consider referral to Ultrasound
alcohol services
Repeat LFTs, FBC, Retic Ct.:
if Gilbert’s confirmed then inform If abnormal USS abnormal
patient and provide information USS normal
Ultrasound &
Refer to Liver Specialist for possible:
Liver Test Panel:
- Viral Hepatitis
- Hepatitis B & C Abnormal USS
Manage in Primary Care: Isolated raised LFTs but - ALD with Advanced Fibrosis
- Autoantibodies appearances
Lifestyle advice and repeat LFTs normal USS and Database - PSC, PBC, Autoimmune Hepatitis
- Ferritin / Transferrin satn and/or
in 1 year - Gallstone disease
- Caeruloplasmin Abnormal - Hepatic Vascular Disorders
- Immunoglobulins Liver Test Panel - Hepatic Metabolic Disorders
- A1 antitrypsin
Consider urgent referral pathway for
suspected Hepatic and Biliary
Fatty Liver Suggested by USS and/or Malignancy
Liver Test Panel Negative for Other Pathology
Page 2
Pathway Created Dec 2013 Reviewed Feb 2016
Clinical contact for this pathway: Prof William Rosenberg william.rosenberg@nhs.uk Next Review Due Feb 2019
 Abnormal Liver Function Tests Guidance
This guidance has been developed in collaboration with local specialists in Camden and Islington.
This is to assist GPs in decision making and is not intended to replace clinical judgment.

Reassess risk annually Fatty Liver Suggested by

If LFT abnormalities persist Ultrasound and/or
Liver Test Panel negative for other
pathology
Fatty Liver only on Ultrasound Fatty Liver on Ultrasound or Liver
Use EMIS Fatty Liver Template Test Panel Negative
with excess Alcohol Consumption
>21U/Week (14U/Week proposed) ♂, without excess Alcohol
>14U/Week ♀ Enter code J610 Consumption
Enter code J61y1

Counsel to stop drinking + Determine risk of

Calculate FIB4
Consider referral to alcohol Advanced Fibrosis
Services
Manage in primary care
Consider referral to
secondary care for < 1.30 1.30 – 3.25 > 3.25
persistently abnormal LFTs

Low Risk Request ELF Test High Risk

Once alcohol of Advanced < 9.5 (NEW biochemistry > 9.5 of Advanced
issue addressed Fibrosis blood test) Fibrosis
Separate gold top
serum sample
Primary Care management of Fatty Liver:
is part of metabolic syndrome / CVD risk Factor
Assess cardiovascular risk and treat
Cholesterol – QRISK & Consider Statin Refer to Secondary Care
If no longer high risk, discharge to - For assessment of liver disease
Can still initiate statin if ALT raised due to fatty liver
primary care with Follow-up plan - For management of advanced fibrosis
Diabetes Alcohol Hypertension
- >10% Weight loss - Screening and treatment of Portal
- Annual LFTs Hypertension
- Reassess risk of advanced fibrosis - HCC screening and management
(as above) in 1 year if LFTs still abnormal

References
Fibrosis stratification in NAFLD based upon:
FIB-4 McPherson S et al. Gut. 2010 Sep;59(9):1265-9. FIB4: (age [yr]x AST [U/L]) / ((PLT [109/L]) x (√ALT [U/L]))
ELF: Enhanced Liver Fibrosis Test Rosenberg et al. Gastroenterology. 2004 Dec;127(6):1704-13.
Combining ELF and FIB4 in NAFLD Tanwar et al. HEPATOLOGY. 2012, 56, 264A.

Clinical contact for this pathway: Prof William Rosenberg william.rosenberg@nhs.uk Pathway Created Dec 2013 Reviewed Feb 2016
Next Review Due Feb 2019
Primary Care Management of raised serum
Ferritin.
This guidance has been developed in
collaboration with local specialists in Camden
and Islington. This is to assist GPs in decision Raised Serum Ferritin
making and is not intended to replace clinical
judgment.

Transferrin saturation < 45% Transferrin saturation > 45%

Consider:
infection, inflammation, alcohol, Refer to hepatology
diabetes, BMI, haematological
disease

Ferritin > 450 mcg/l Ferritin < 450 mcg/l

Repeat ferritin and transferrin Repeat ferritin and transferrin

saturation after 1 month saturation after 3 months

Still High Normal

Perform: FBC, film, retics, haptoglobin, Stop: Manage

LFTs, HbA1C, TFTs complicating factor
Liver ultrasound
Refer hepatology: Attach all results

Pathway Created Dec 2013 Reviewed Feb 2016

Next Review Due Feb 2019
Primary Care Management of elevated serum GGT.This guidance has been developed
in collaboration with local specialists in Camden and Islington. This is to assist GPs in
decision making and is not intended to replace clinical judgment.

Isolated GGT Elevation

No significant alcohol Consumption

>21U/Week (14U/Week proposed) ♂ Other abnormal LFTs Suspected NAFLD Alcohol
>14U/Week ♀

Abnormal LFT Pathway NAFLD Pathway Alcohol Pathway

Repeat GGT after I month –

still elevated

Consider changing non-

essential medication
 Review medications
 Perform abdominal US Referral if abnormal liver US
 Assess BMI cardiovascular risk scan
 Full blood count
Q risk / lifestyle advice
Treat metabolic abnormalities
No cause identified

Repeat in 6 months with other

Other abnormal LFTs Abnormal LFTs Pathway
LFTs panel including ALP

Perform: FBC, film, retics, haptoglobin,

LFTs, HbA1C, TFTs
Liver ultrasound
Refer hepatology: Attach all results Pathway Created Dec 2013 Reviewed Feb 2016
Next Review Due Feb 2019