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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

Abnormal liver function BMJ 2011;342:d2244 Evaluation of Abnormal Liver Chemistries American College of Gastroenterology January 2017 Approach to Abnormal Liver Tests Naga P.Chalasani MD ACG/FSG Spring Meeting 2013 Oscestop.com Interpretation of Liver Function Tests Assessment of Abnormal Liver Function Tests South and West Devon Formulary and Referral Gwent Clinical Guideline- Abnormal LFTs Davidsons Principles and Practice of Medicine Elseiver 2014 Zakim’s and Boyer Hepatology 7th Edition Elseiver https://patient.info/doctor/
abnormal-liver-function-tests Evaluating the patient with abnormal Liver Function Tests Mescape assessed via http://www.medscape.com
/viewarticle/710045 Guidelines on the management of abnormal liver blood tests Newsome PN, et al. Gut 2017;o.1-14

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