1. LFTs found to be high.
2. Review appointment - review of risk from infection (tattoo/ sexual / blood transfusion), alcohol, fhx, drugs (current, recent and non-prescription), obesity.
3. If high alcohol intake, or other modifiable elements (include consider stopping likely culprit drugs including non- prescription) - advise to reduce intake/stop/change and recheck LFTs in one month and three months.
4. If LFTs back to normal at one month and/or three months advise this was causing LFT abnormalities. Review need for further follow-up.
5. If LFTs continue to be abnormal - check ‘liver screen’ - see attached, and also TSH, FBC/Prothrombin time with repeat LFTs, and arrange abdominal ultrasound. For AST you will need to write ‘discussed with Dr O’Donnell on the biochemistry form’ although no discussion is necessary. The Auto antibodies are 1 serum gel tube on blue microbiology form and the viral serology is a further serum gel tube on a second microbiology form. The haematology should be simple and the rest is on 1 green biochemistry form with one FULL serum gel tube:
   Please see attached copy of the Liver Screen Proforma check-list which covers this (plus FBC/PT/TSH). (Appendix 1)
6. If these tests are normal and no modifiable causes found then repeat LFTs at six months - if features of metabolic syndrome - overweight, fatty liver, diabetic and patient otherwise well, consider annual primary care LFT review. If AlT >100 and/or climbing, consider Gastroenterology referral.
7. If gallstones found – consider referral to General Surgeons.
8. If fatty liver found on ultrasound, for lifestyle advice and alcohol history - sensible alcohol intake, weight loss, exercise, good diabetic control if diabetic. Fatty liver per se is not an indication for referral to Gastroenterology in the absence of abnormal liver function tests, and even with mildly abnormal liver function tests in a patient who has all the features of a metabolic syndrome then not necessarily for Gastroenterology referral - more lifestyle advice as above.
9. Metabolic syndrome refers to a syndrome of insulin resistance with a tendency to overweight and diabetes mellitus. Treatment is basic lifestyle measures – cardiovascular risk assessment and treatment where indicated including Aspirin and Statins, and attempts at weight loss and diabetic control if diabetic. LFTs should always be checked before a Statin is started. Mildly abnormal liver function tests are not a contraindication to starting or continuing a Statin so long as LFTs are monitored.

If blood tests deteriorating obviously refer to Gastroenterology, and if other concerns then either refer or discuss.

In summary - patients with mildly abnormal and stable liver function tests should not be referred to Gastroenterology until some simple baseline investigations have been done, and their LFTs have remained abnormal for over six months - chronic hepatitis.

Liver screen checklist also refers to ascites - this is to cover secondary care too when inpatients with ascites would have this tapped for diagnostic purposes.

Well patients with mildly abnormal and stable abnormal liver function tests should not be referred to Gastroenterology until some baseline investigations have been done and LFTs have remained abnormal for six months or over - in acute or chronic hepatitis obviously we would be happy to discuss issues where the patients do not fit these guidelines or where there are other concerns.

Three likely outcomes for well patients with abnormal liver function tests: -

1. Liver screen and ultrasound shows gallstones only –consider referral to Surgeons.
2. Likely non-alcoholic fatty liver disease on basis of ultrasound and negative liver screen - lifestyle advice and management +/- refer if further concerns or deteriorating liver function tests.
3. Diagnosis not clear on basis of screening tests. Consider referral if further concerns and/or LFTs deteriorating.

Also please note that patients with obstructive jaundice should be d/w or referred directly to
surgery and not to GI.

View the liver screen checklist as a PDF.