Guidelines on the management of abnormal liver blood tests, Gut 2018

Newsome PN, et al. Gut 2018;67:6–19. doi:10.1136/gutjnl-2017-314924

Guidelines on the management of abnormal liver.pdf

Recommendations list

Recommendation 1: Initial investigation for potential liver disease should include bilirubin, albumin, alanine aminotransferase (ALT), alkaline phosphatase (ALP) and γ-glutamyltransferase (GGT), together with a full blood count if not already performed within the previous 12 months. (level 2b, grade B)

Recommendation 2: Abnormal liver blood test results should only be interpreted after review of the previous results, past medical history and current medical condition. (level 5, grade D)

Recommendation 3: The extent of liver blood test abnormality is not necessarily a guide to clinical significance. This is determined by the specific analyte which is abnormal (outside the reference range) and the clinical context. (level 5, grade D)

Recommendation 4: Patients with abnormal liver blood tests should be considered for investigation with a liver aetiology screen irrespective of level and duration of abnormality. Abnormal refers to an analyte which is outside the laboratory reference range (level 2b, grade B)

Recommendation 5: In adults a standard liver aetiology screen should include abdominal ultrasound scan (USS), hepatitis B surface antigen, hepatitis C antibody (with follow-on polymerase chain reaction (PCR) if positive), anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin and transferrin saturation. (level 2b, grade C)

Recommendation 6: In children, ferritin and transferrin saturation may not be indicated, but autoantibody panel should include anti-liver kidney microsomal antibody and coeliac antibodies. Alpha-1-antitrypsin level and caeruloplasmin (age >3 years) should be included, and abnormalities discussed with an appropriate inherited metabolic disease specialist. (level 2b, grade C)

Recommendation 7: Adults with NAFLD should undergo risk stratification to determine the extent of their liver fibrosis.
   - First-line testing should use either fibrosis-4 (FIB-4) or NAFLD Fibrosis Score (NFS) (level 2b, grade B). Calculation facilities for FIB-4 and NFS should be incorporated in all primary care computer systems. (level 5, grade D)
   - Second-line testing requires a quantitative assessment of fibrosis with tests such as serum enhanced liver fibrosis (ELF) measurements or Fibroscan/acoustic radiation force impulse (ARFI) elastography. (level 2b, grade B)
   - We recommend that hepatologists at a local level champion this idea and discuss it with commissioners of health to deal with the burden of liver disease in their area.

Recommendation 8: Consider referral to alcohol services for all adults with alcohol-related liver disease (ARLD) with evidence of alcohol dependency as defined by an AUDIT score of >19. (level 3b, grade C)

Recommendation 9: Harmful drinkers should undergo risk stratification with clinical assessment and Fibroscan/ARFI elastography. Adults should be referred to secondary care if there is evidence of advanced liver disease (features of cirrhosis or portal hypertension on imaging or from blood tests) and/or Fibroscan reading is >16 kPa (if available). (level 2b, grade B)

Research Recommendation 2: Further evidence is required to establish the most cost-effective approach to identify patients with ARLD and NAFLD at risk of having advanced liver fibrosis.

Recommendation 10: Adults with abnormal liver blood tests, even with a negative extended liver aetiology screen and no risk factors for NAFLD, should be referred/discussed to a gastroenterologist with an interest in liver disease/hepatologist for further evaluation. (level 4, grade C)