Referral pathway for abnormal liver bloods in over 16’s

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.

• NICE (NG50): Cirrhosis in over 16s: assessment and management
• BSG Guideline: Management of abnormal liver blood tests
• Gilbert's patient information

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.

• 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