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Abnormal Liver Function Tests ( LFTs)

Abnormal or deranged Liver Function Tests: Assessment in primary care and further investigations guidance.

Pattern of LFT derangement’s – try and 
recognise the clinical pattern- hepatitic , obstructive , synthetic failure , isolated raised bilirubin with otherwise normal LFTs , alcohol related liver disease.

Hepatitic –Damaged liver cells release liver 
enzymes, Transaminases
 ALT→ specific to liver AST→ source liver , heart , skeletal muscles , kidneys, pancreas NAFLD screen / pathway – see topic on A4Medicine and external links

Obstructive –Cause can be different based upon location of blockage. Lumen ( Gallstone in bile duct ) Wall ( cholangiocarcinoma , stricture ) External ( cholecysttis , ascending cholangitis , pancreas ) Alkaline Phosphatase GGT Bilirubin

Synthetic failure –Jaundice , low 
albumin , prolonged INR OR Suspected Malignancy

Isolated rise in bilirubin-See below and chart on bilirubin + external links Isolated raised Br is most commonly caused by Gilberts syndrome If anaemic consider hemolysis If marked elevation of unconjugated Br- consider rarer causes as Crigler-Najjar syndrome

Liver screen –FBC / Clotting screen / Ferritin U&E / TFT / Glucose / Lipids / Albumin Viral screen ( ABCE ) Immunoglobulin electrophoresis Alpha 1 Antitrypsin Autoantibody screen -ANA , AMA , ASMA , LKM Transferrin saturation Ceruloplasmin ( Wilson’s dis ) Coeliac screen

New presentation -Pt Non jaundiced, assess Alcohol use Drugs particularly last 3/12 ( prescribed , Illicit ) Hepatitis risk factors ( Eg Transfusion , tattoos , IVDU ) Travel Lipid disorder , BMI , Diabetes and Family history Occupational risk

Red flags-Wt loss Change in bowel habit Dysphagia Rectal bleeding Abdominal mass Lymphadenopathy

Unwell patient –Fever Encephalopathy Ascites Abnormal pain / Abdominal tenderness Jaundice

LINKS AND RESOURCES

 

A short explanation for patients from American Liver Foundation on LFTs- 3 page LFT handout can be very useful as abnormal LFTs is a frequent cause of patient encounter in primary care https://liverfoundation.org/for-patients/about-the-liver/the-progression-of-liver-disease/diagnosing-liver-disease/#1507303054586-33792079-1a22

British Liver Trust Patient information on Liver function Tests with a publication which can be downloaded -excellent work https://britishlivertrust.org.uk/information-and-support/living-with-a-liver-condition/tests-diagnosis-and-screening/

American Journal of Gastroenterology ACG Clinical guideline: Evaluation of Abnormal Liver Chemistries Jan 17 https://journals.lww.com/ajg/Fulltext/2017/01000/ACG_Clinical_Guideline__Evaluation_of_Abnormal.13.aspx

Non-alcoholic fatty liver disease A4Medicine https://www.a4medicine.co.uk/non-alcoholic-fatty-liver-disease-nafld/

NAFLD fibrosis score https://nafldscore.com/

RCGP Liver disease toolkit https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/liver-disease-toolkit.aspx

 

References

  1. Abnormal liver function BMJ 2011;342:d2244 https://www.bmj.com/content/342/bmj.d2244
  2. Continuing Medical Education Questions: January 2017: ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistrie Umashanker, Renuka MD, FACG1American Journal of Gastroenterology: January 2017 – Volume 112 – Issue 1 – p 36 doi: 10.1038/ajg.2016.571https://journals.lww.com/ajg/Fulltext/2017/01000/Continuing_Medical_Education_Questions__January.14.aspx

  3. Approach to Abnormal Liver Tests Naga P.Chalasani MD
    Naga P. Chalasani, MD, FACG Professor of Medicine and Cellular & Integrative Physiology
    Director, Division of Gastroenterology and Hepatology Indiana University School of Medicine
    ACG/FSG Spring Meeting 2013 Conflicts of Interest ACG Regional Postgraduate Course -Florida  American College of Gastroenterology ACG/FSG Spring Meeting 2013
  4. Oscestop.com Interpretation of Liver Function Tests
  5. Assessment of Abnormal Liver Function Tests South and West Devon Formulary and Referral https://southwest.devonformularyguidance.nhs.uk/referral-guidance/western-locality/gi-liver/abnormal-liver-tests
  6. Gwent Clinical Guideline- Abnormal LFTs
  7. Davidsons Principles and Practice of Medicine  Elseiver 2014
  8. Zakim’s and Boyer Hepatology 7th Edition Elseiver
  9. Patient UK Abnormal Liver Function Tests via  –https://patient.info/doctor/
abnormal-liver-function-tests
  10. Evaluating the patient with abnormal Liver Function Tests Medscape assessed via http://www.medscape.com
/viewarticle/710045
  11. Guidelines on the management of abnormal liver blood tests Philip N Newsome,1,2 Rob Cramb,1 Suzanne M Davison,3 John F Dillon,4 Mark Foulerton,5 Edmund M Godfrey,6 Richard Hall,7 Ulrike Harrower,8 Mark Hudson,9,10 Andrew Langford,11 Anne Mackie,8 Robert Mitchell-Thain,12 Karen Sennett,13,14 Nicholas C Sheron,15 Julia Verne,8 Martine Walmsley,16 Andrew Yeoman17 Gut Online First, published on November 9, 2017 as 10.1136/gutjnl-2017-314924 https://gut.bmj.com/content/gutjnl/early/2017/11/09/gutjnl-2017-314924.full.pdf

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