Abnormal Liver Function Tests

Primary Care Knowledge Boost Podcast 2. Abnormal liver function tests. Hello and welcome to Primary Care Knowledge Boost. I'm Dr. Sarah McDermott. And I'm Dr. Lisa Adams. And today we're going to be talking to consultant gastroenterologist Dr. Bliss.

All right, so welcome back to Premier Care Knowledge Boost. With us today, we've got Dr Bliss talking to us about gastroenterology. Do you mind just introducing yourself, Dr Bliss, for the new listeners? Sure, yeah. My name's Phil Bliss. I'm a consultant gastroenterologist. at Wigan I've been a consultant since 2000 most of that time spent in Wigan but I spent about seven eight years working in Liverpool but returned back to work in Wigan two years ago

Fantastic. So we're going to be talking about abnormal liver function tests. Did you find that these are quite high referral areas in secondary care? Yeah, the bulk of our outpatient work is... reflux disease, dyspepsia, reflux and dyspepsia, irritable bowel syndrome, and abnormal liver function tests. We're seeing an awful lot of patients with abnormal liver function tests now. I think as more patients are having liver function tests done in primary care, and I think we're...

getting a lot more sensitive to noticing small abnormalities in them. The vast majority of patients we see with abnormal liver function tests don't have serious liver disease. There's almost... an epidemic of what we call NAFLD, non-alcoholic fatty liver disease. And I would suspect that 90 to 95% of all the patients referred into us.

in secondary care with abnormal other function tests have NAFLD. That's quite a high number. Yeah. I suspect it reflects our changing lifestyles. People become more overweight. People have high cholesterol.

drink a bit more than they should without necessarily having serious alcoholic liver disease but just all those factors adding together can give them a degree of fatty liver and these minor abnormalities of the liver function tests. Well we're going to touch on NAFLD later but we might as well speak a bit about it.

now that you've brought it up. So what would be the usual findings on a liver function profile for someone who has an apple? You tend to see a minor elevation of the transaminases, twice, three times the upper limit of normal. Very rare to see significant elevations of bilirubin or significant elevations of alkaline phosphatase. It's mainly sort of...

modest elevations of transaminases. And if we've got somebody who's showing those kind of mild changes, what would be your first line? What would you do with those patients? Okay, we'll tend to test with any patient with any abnormality of liver function tests. We do what we call a chronic liver disease screen, which...

screens for the more serious causes of abnormal liver function tests that we don't want to miss. And that would include viral hepatitis markers, hepatitis B and hepatitis C markers. We check for the sort of metabolic cause of liver. problems, mainly haemochromatosis, so we check ferritin. In a young patient, we check seroplasmin. We very, very rarely see Wilson's disease, but if you don't do the test, you won't find it out.

but so in under 45s you do cereoplasmin check alpha-1 or two trips in for other metabolic causes again these are rare small print diseases but but important to check out for and then you look for the uh autoimmune liver conditions, autoimmune chronic active hepatitis, and primary bulecyrosis. And we do that by checking the autoantibular profile and the immunoglobulin profile. We'd also suggest checking someone's lipids because of...

NAFLD and checking for diabetes. And also celiac disease. Sometimes celiac disease can present with an isolated elevation of ALT. So that's what we call our chronic liver disease screen. And in addition to blood tests, we would also... suggest you do a scan, an ultrasound scan. And in terms of the blood tests that you mentioned there, would you screen everybody for all of those or would you target based on symptoms? We just do it on everybody, a blanket chronic liver disease screen.

And these are all tests that can be done in primary care. Yeah, they are definitely. And for those patients who we only see a minor elevation in their ALT. for example, just in the 60s range, would you necessarily be doing full liver screens on those patients or is that something that you'd just monitor? Certainly, if you think you're referring to secondary care, then I don't think you should refer to secondary care without having done a liver screen.

We do have guidelines of the management of abnormal liver function tests, which we often send out to GPs in the hope of guiding them with the investigation of this patient, but also to help guide their future practice so that they know what to do. Recently there's been a...

a very helpful tool called a NAFLD score, which you're able to risk stratify patients with fatty liver. So if you do your chronic liver disease screen and everything's normal and you do ultrasound scan and it shows they've got a fatty liver and they're a bit overweight. they'd drink possibly more than

They're sure they've got slightly high cholesterol. They're most likely diagnosed if they've got NAFLD. So you can do a risk stratification score, which is based on the AST, the ALT, the albumin, the platelet count, the patient's BMI, and whether or not they've got diabetes. you a score it's really cumbersome score because it starts off as a minus number and it goes in range from minus number to a positive number and so you can have a game can be quite confusing for people a score of minus three

It's actually a good score. So it looks like a big number. So you've got a score of three, but it's actually minus three. And minus three is lower than minus two. I see. And people can get confused with the minus number. So if you look at that, and we include the reference to dual NAFL score on our abnormal...

liver function test guidelines. So we get patients who come to clinic and we will calculate the NAFL score and hopefully by putting that in our letter back to GPs, patients, the GPs will be aware of this concept of the NAFL score and to risk stratify them. And if they've got a... low risk of fibrosis, then we don't need to see them again. We probably didn't even need to see them in the first place. If they have a...

intermediate or high risk NAFLD score, then we should be seeing them in secondary care and doing what we call a fibrous scan. So will the, if we do that score online, will it stratify it into the kind of low intermediate and high for us? Yeah, I've got the little app on my phone. It's just typing the numbers.

and away you go. So if they're low risk we don't really need to do anything else. Would you monitor them in primary care at all or just give them the lifestyle advice? Identify whichever risk factor they've got. They've often got more than one so look at that and then just keep an eye on things.

higher ones will be referring on to you anyway. And I suppose if you do monitor them, you can always repeat the NAFL score in a year. And if it goes from low risk to intermediate risk, then you can refer them back.

And just mentioning, because we've kind of touched on ALT and if it's slightly raised to do the screening things, at what stage would you be worried about an ALT on the day? So say the results come back to us and it's a really high ALT, which people need to come in urgently to hospital?

with LFTs being abnormal. I mean, bilirubin is probably the most important abnormal of effect function test which needs urgent attention because, Joan, this is generally a bad thing to have. If you look at all the different suspected cancer...

referral pathways and the yield for having cancer if you've got jaundice then that's our yield for finding cancer in those patients is very high so anybody who's jaundiced should be seen quite quickly and we do have a fast track referral system for patients with jaundice

That works very well. So less worried about high ALTs. Less worried about high ALTs. Brilliant. Especially, I guess, if the patient's asymptomatic. It's unusual for ALTs to be elevated much over 200 or 300 in somebody with fatty liver disease. above 300 and hopefully that you know you would do your chronic liver disease screen that's more suggestive of maybe autoimmune

liver disease or sometimes you get drug-related liver injury and that's when you tend to get ALTs in the sort of 500s to 1000s. ALTs over 1000 is often due to viral hepatitis or... paracetamol overdose to drug-induced hepatitis. So the low ALTs tend to be NAFLD, possibly alcoholic liver disease. Medium elevation of your ALT tend to be your autoimmune liver diseases. And anything over the thousands, think virus or...

Or drugs. Yeah, that's useful to know as well for differentiating them. And so just thinking about bilirubin in isolation, when do you think we should be worried about a slightly raised elevation in just bilirubin alone?

Isolated elevation of bilirubin is most often Gilbert's. So when I was saying about bilirubin before, so if you've got bilirubin with another abnormal of a function test, that's a worrying sign. An isolated elevation of bilirubin is most likely Gilbert's syndrome, and you can do a differential bilirubin count too.

determine that. And often what you'll find is when you look back through the notes and through the records, they had Norma Billy Rubin in 2012 and again in 2006 and again in 2008. Going back through time. So you should look at...

The sort of trend. So an isolated elevation of bilirubin, I wouldn't be as worried about as an elevation of bilirubin in association with a raised alkaline phosphatase or a raised ALT. So we've talked about bilirubin. The main test you would do with an isolated bilirubin would be the split.

Billy test. Through the conjugated and unconjugated Billy Rubin. And if it's simple, Gilbert, we don't need to do anything with them. They don't need to come see you. No, no. Often, this is the type of things that we get requested for on advice and guidance. We audited the...

the different classes of referrals we got on advice and guidance and advice on abnormal over function tests was one of them and that provides us with the opportunity to send back our guidelines how to manage abnormal over function tests and we often get another aspect is the is this gilbert's and often

I can go back and say, yes, it is. And hopefully that provides the guidance and reassurance that GPs are looking for. Fantastic. That's really useful to have as well, because it's quite a fast response from secondary care, but it means that the patient isn't inconvenienced and doesn't have to wait for an appointment. So we'll talk about it by...

against maybe at the end and so for just an isolated raised alkaline phosphatase how do you think in we should be managing those i mean alkaline phosphatase is often associated with can be raised with primary bilaterosis can be often with but patients with gallstone disease will often have symptoms that go along with raised alkaline phosphatase. You can have a raised alkaline phosphatase in NAFLD, and that's why it's good.

to do the full liver screen in every patient rather than target it. Because you do get overlap in abnormal liver function tests, it's important to do the full liver screen in all patients. Typically, gallstone disease is associated with slightly lower...

ALT and slightly higher alkaline phosphatase. But if somebody's got cholangitis from the gallstone disease, the ALT can be very high and people can get caught out. This is usually in the secondary care setting, the patients come in with very high ALT. They've got gallstones and it's because they've got cholangitis and the inflammation, the sepsis and the biliary tree drives the ALT to be very high. So there are sort of rules of thumb.

in terms of abnormal liver function tests. But as with all cases, rules are there to be broken and you can have slight deviations from those rules. And that's why it's good practice to do the full liver screen. and imaging if you do full liver screening and imaging you won't go too far wrong and you won't get caught out too often and then just moving on to the controversial gamma gt test yeah should we be doing this test on anybody when is it indicated when should we be doing it

If you took GammaGT off the set of... In fact, you don't get GammaGT on a set of lever function tests. You have to... specifically requested, I wouldn't bother with a gamma-GT. I suppose the one proviso would be if you have isolated elevation of alkaline phosphatase and you want to know is it bony alkaline phosphatase or is it hepatic alkaline phosphatase, then erase gamma-GT.

might put you down that route of hepatic-raised alkaline. But you're probably going to do a full liver screen and check them out anyway. An isolated elevation of gamma-GT is of no real prognostic. and I wouldn't worry too much about GammaGT. I can't remember the last time I requested a GammaGT. So if we've got absolutely normal liver function tests, no symptoms, and this one raised GammaGT, we don't really need to be worrying about it. Fantastic.

I think the only other question I had about... the kind of liver function tests was if we have a normal liver screen and a normal ultrasound but we still have this persistently raised say ALT do we need to be referring them on or are we happy that we've covered everything with the scan and the most of the time it'll be generally always be fatty liver and if you do NAFLD score that should be fine. Okay, brilliant.

So even if there's no changes on the ultrasound scan for the liver and we've done a liver screen that's reasonably normal, would we still be treating those patients as potential NAFLD? I mean, you can always refer to advice and guidance. You know, if you've done a liver screen and you've done an ultrasound scan and you're not quite sure it doesn't fit. But most patients, they'll be a bit overweight. They'll have a slightly high cholesterol or they drink.

30 units a week or whatever and so you can always nearly always find something to explain and a negative chronic liver disease screen is reassuring a normal ultrasound scan is reassuring good an alt of 60 or 70 with that wouldn't worry, wouldn't worry too much. But if in doubt, send from their own advice and guidance. I think it does sound like another good use of the advice and guidance system to be able to do that as well. And in terms of medications causing liver function abnormalities,

What are the big culprits in terms of medications that you commonly find? I think the big one is statins, isn't it? I think that's what GPs worry a lot about. And a lot of the time they have abnormal liver function tests because they've got...

high cholesterol and the actual treatment is statin. So you sort of statin and you think, oh, the statin's caused the abnormal liver function test. Well, it isn't. It's the fatty liver that's caused the abnormal liver function test and the statin is there to treat it. So I wouldn't...

I wouldn't let that put me off starting a statin in somebody who needed a statin. Okay, brilliant. That's good to know. And so other than statins, are there any other medications that are quite common to find causing... liver abnormalities? We sometimes see patients with antibiotic-associated abnormal function tests and augmentin is the...

is the classic one, and flucaloxacillin, they can cause cholestatic liver function tests. But I suppose the message is that any patient with abnormal liver function tests, you need to do a drug history because...

There's a long list of drugs that can cause liver problems and just cross-reference them against your abnormal liver function test. That makes sense. And see, is there anything in there that could be causing this? Brilliant. That's great to know, Dr. Bliss. And I guess that's everything for today. So thank you very much for coming and speaking.

to us we do really appreciate it and we'll see you next time whenever we meet up to do the irritable bowel syndrome podcast so yeah I think that was a really good discussion we had today Sarah yeah I really liked the whole thing it was really useful just to run

through liver screening again. Actually, it's been a while since I've thought about each of the conditions, particularly things like celiac screening there. Yeah, definitely. I think I took away most about the NAFLD scoring, about how we can kind of do that ourselves.

in primary care and get a bit of a risk stratification to work out who should be getting referred. And what we'll do for everybody is we'll include a link in the podcast description telling them where to go to access a NAFLD score that's really basic and easy to use.

use and you can just save it to your bookmarks and then you'll be able to do it in the future yeah and we have mentioned quite a lot about the advice and guidance there as well yes and that was quite useful just to go through appropriate uses of it because it's still reasonably new so It's nice to know that things like liver function

test questions and things that's quite an appropriate way to use it yeah i think i'll definitely be doing that more in future myself and kind of linking from that with the abnormal lfts and there are pathways that have been developed by wigan and with regards to to how

to manage abnormal LFTs. Now, we did struggle ourselves to try and find those on the SharePoint website, but we have asked the CCG to try and make them a little bit more obvious. So we're hoping that they're going to be in the GP section with the other pathway. like the ENT and urology ones so that's where you should be able to go and have a little read of that yeah brilliant and then the only other bit to talk about is how you can kind of

feedback to us and get back in contact with us so these are all still relatively new and we want to make sure that we're doing the best that we can and targeting the podcasts for everybody appropriately and so we have done a survey it's very quick and short it's only going to take you five minutes and we've included the link

the podcast description and we'd be really grateful if you could take the time to fill it in for us just to give us feedback we don't really mind about the good feedback but if you can tell us what we could do better then we can try and make these the best podcasts that we can and for everybody

Yeah, and even technical issues. That'd be great to know. Yeah, it would be really useful to know that. Grace, yeah. We also have ways to contact us otherwise. We're on Twitter at Primary Care Knowledge Boost Podcast. And our handle is pckbpodcasts. And you can email us as well. So it's primarycarepodcasts at gmail.com. Yeah, and you can contact us in any way. We're very happy to hear from everybody.

So I guess all that's left to say is that we'll look forward to seeing you all next time. We're going to be, like I said, meeting up with Dr Bliss to do irritable bowel syndrome. So we'll get in touch with everybody and let you know when that's available to listen to. But for now, I guess that's everything. Yes. Thank you very much for listening. Thank you for listening. Until next time on Primary Care Knowledge Boost.

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