Abnormal liver blood results referral pathway (Over 16’s) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Referral pathway for abnormal liver bloods in over 16’s

Consider History:
Alcohol (present and past), Drug use (prescribed, OTC or illicit), Hepatitis risk, Foreign travel / Ethnicity, Metabolic disease, Occupational risk, Autoimmune clues and Co-morbidities
Examination:
Assess for stigmata of liver disease: Spider navei, Gynaecomastia, Auxilliary hair loss, Bruising, Fetor, Icteric, Muscle wastage, Palmar erythema, Dupytrens contracture, Flapping / tremor
Clinical pattern recognition:
Identify dominant enzyme abnormality & ensure full liver screen prior to SCI referral. See criteria below.

 

ALT/AST↑ (hepatic)

If hazardous alcohol intake: see pathway A

If MASLD: see pathway B

Normal USS / Negative liver screen and No MASLD risk factors

ALP /GGT1↑ (cholestatic)

Abnormal USS and / or positive liver screen

OR Normal USS and negative liver screen with ALP & GGT remaining abnormal.

Isolated Bilirubin

(With otherwise normal liver bloods)

  1. If Gilberts: inform patient and provide information.
  2. Check for haemolysis and, if present, refer to haematology
RED FLAGS:

Impaired liver synthetic function (low albumin, prolonged coagulation / INR, bilirubin elevation with abnormal liver bloods)

Jaundice / Fever / RUQ Pain / Weight loss.

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Liver bloods remain abnormal:

Refer to gastroenterology (or viral hepatitis team) for further assessment.

Refer to Gastroenterology or HPB Surgical team as defined by results of USS and bloods.

URGENT REFERAL:

Request urgent USS

Refer to Gastro or HPB surgical team dependant on clinical findings.

Full liver screen includes USS, liver bloods including GGT and AST, Hep B surface antigen, Hep C antibodies, AMA, ASMA and ANA antibodies, serum immunoglobulins and simultaneous ferritin and transferrin saturations.

 

Ultrasound scan (USS)

When to request USS as part of a full liver screen

Historically, an abdominal ultrasound has been requested as part of the full liver screen. In line with  BMUS and local guidelines agreed with NHS Highland Radiology department, please be aware that an ultrasound may not always be justified as part of first-line investigations.

When is a USS justified as part of full liver screen

When is a USS NOT justified as part of full liver screen
  • ALT or ALP is greater than 2.5 x ULN or rising suddenly
  • Patient has signs and symptoms of advanced liver disease (Please see referral pathway for abnormal liver bloods in over 16s)
  • Suspicion of biliary obstruction or cholecystitis
  • Suspicion of malignancy
  • Isolated single liver enzyme rise (Please see referral pathway for abnormal liver bloods in over 16s)
  • Asymptomatic patient with single episode of mild to moderate rise in liver enzymes
  • Patient with known high risk factors for MASLD (type 2 diabetes, obesity, hypertension, hyperlipidaemia): Where MASLD is the likely diagnosis, fibrosis risk stratification (pathway B) is more useful than ultrasound.
    Patient on drugs known to cause hepatic enzyme rises (eg. Statins):  please stop drug and repeat liver enzyme tests in 1 to 3 months.

If there is clinical doubt as to whether an USS should be arranged prior to referral to Gastroenterology, please contact: livernursespecialists@nhs.scot

Please record relevant information on Radiology request form:

  • Which LFTs are deranged, by how much and for how long?
  • Patient symptoms (including weight loss)
  • A specific diagnosis (if known)

Abbreviations

Abbreviation Meaning
OTC Over the counter
USS Ultrasound scan
ALP Alkaline phosphatase
GGT Gamma-glutamyl transferas
INR International normalized ratio
RUQ Right upper quadrant
HPB Hepatico-pancreatico-biliary
AST Aspartate aminotransferase
AMA Anti-Mitochondrial Antibody 
ASMA Anti-smooth muscle antibody
BMI Body mass index
LFT Liver function test
ANA Antinuclear antibody
BP Blood Pressure
PCR Polymerase chain reaction
MASLD Metabolic dysfunction associated steatotic
BBV Blood borne virus
BSG British Society for Gastroenterology
DBS Dry blood spot
NaV Hepatitis A virus
HBV Hepatitis B virus
HCV Hepatitis C virus
HBV eAg Hepatitis B virus e antigen
ALD Alcohol related liver disease

Editorial Information

Last reviewed: 20/07/2021

Next review date: 31/07/2025

Author(s): Liver guideline and pathway group.

Version: 1.5

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr A Broad, Consultant Gastroenterologist and Liver nurse specialist.

Document Id: TAM666