The video version of this podcast can be found here:

·      https://youtu.be/rIX46swVSfg

This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology and a number of NHS organisations in the UK. Here I focus on the hepatitic pattern of abnormal LFTs. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary guide can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS

The resources consulted can be found here:

BSG- British Society of Gastroenterology:

·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests

·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)

o  First published on:

o  BMJ article:

o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only.

This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description.

Right, let’s jump into it.

We have to start by remembering that liver disease develops silently and at earlier stages liver enzymes may be normal, and, if they are high, the degree of abnormality is not necessarily related to the severity of the underlying condition.

We also need to remember that AST and ALT are enzymes present in the liver cells and the levels increase in response to cell injury or death. ALT is considered more liver-specific while AST is also present in skeletal, cardiac and smooth muscle and so may be elevated in patients with an MI or myositis.

An AST:ALT ratio of >1 is a non-invasive marker of liver fibrosis. In early liver disease, AST and ALT can be normal, but the high AST:ALT ratio is usually present even if both values are normal.

So, what should we do when confronted by abnormal LFTs?

First of all, we should not think that the extent of abnormality of the LFTs correlates necessarily with the severity of the problem. Common conditions leading to chronic liver disease like NAFLD, and hepatitis C are frequently associated with only mild or moderate LFT abnormalities.

Also, we should not think that the duration of the abnormal LFTs is a reflection of clinical significance, so repeating the LFTs hoping that they will improve is not necessarily the way to go. We need to remember that in many chronic liver diseases such as hepatitis C and NAFLD, the LFTs returning to normal do not necessarily imply the resolution of the disease.

Therefore, the recommendation is that most patients with abnormal LFTs should have a full liver screen irrespective of level and duration of the abnormality.

What is a full liver screen?

This should include an USS, hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin.

And finally, let’s remember that there are three common patterns of abnormal LFTs:

1. An Isolated raised bilirubin with otherwise normal liver tests
2. A Cholestatic pattern: normally showing a high ALP and GGT
3. A Hepatitic pattern: with a raised ALT and AST indicating hepatocellular injury, like, for example, viral hepatitis, NAFLD, and ARLD. The hepatitis pattern is the section that we will concentrate on today.

The three most common causes of liver disease are alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis.

How do we manage these patients?

First of all, if there are signs of synthetic liver failure like unexplained clinical jaundice, a low albumin or a high INR or if there is suspicion of malignancy, for example because of weight loss or marked cholestasis, we should urgently refer or admit the patient.

If the patient has a hepatitic picture with a high ALT and AST, the management will depend on the level of liver fibrosis, which we can estimate using non-invasive fibrosis markers.

The majority of patients presenting with a hepatitic pattern will have either NAFLD or ARLD.

So let’s start with NAFLD.

Following a liver USS, for patients with NAFLD or liver disease of unknown cause, we will estimate the risk of fibrosis using the FIB4 or NAFLD fibrosis score. These scores have cut off points for low, intermediate and high risk of fibrosis.

If there is a low risk of advanced fibrosis, we will just manage the risk factors in Primary Care and reassess periodically, generally every 2 to 5 years. In primary care, the treatment for NAFLD is weight loss, alcohol advice, the reduction of cardiovascular risk and the management of co-morbidities.

If the risk of fibrosis is intermediate, these patients should have second-line tests such as an enhanced liver fibrosis blood test, also known as an ELF test, or imaging such as a FibroScan or elastography.

However, patients with very high scores representing a high risk of fibrosis, should be referred to hepatology without waiting to do an ELF test, Fibroscan or elastography.

Let’s now look at ARLD. For patients with ARLD we will assess their alcohol intake, using the AUDIT C or the full AUDIT questionnaire if necessary. Depending on the severity of the alcohol intake, we will give them a brief intervention, refer them to alcohol services or to hepatology for further investigations.

The treatment of ARLD is to stop drinking harmfully, and for many this usually means compl