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Guideline of the month – updated guidance on abnormal LFTs

The guideline

The British Society of Gastroenterology has published an extensive update of its 2000 guidance on the management of abnormal liver blood tests. It covers how an abnormal test should be defined, what should be included in a liver blood panel and managing abnormal results.

Key points for GPs

  • Initial tests should include bilirubin, albumin, alanine aminotransferase, alkaline phosphatase and γ-glutamyltransferase, as well as an FBC if not done in the previous 12 months.
  • Abnormal tests should be interpreted after a review of previous results, medical history and current symptoms.
  • The degree of abnormality doesn’t necessarily correlate with clinical significance – this depends on which analyte is outside the reference range.
  • Any abnormal results should prompt consideration of a liver aetiology screen. In adults this should include abdominal ultrasound, hepatitis B surface antigen and hepatitis C antibody.
  • Children should have an autoantibody panel with antiliver kidney microsomal antibody, coeliac antibodies, and, in over-threes, α-1-antitrypsin level and caeruloplasmin. Abnormalities should be discussed with an inherited metabolic disease specialist.
  • Adults with abnormal LFTs, even with a negative aetiology screen and no risk factors for non-alcoholic fatty liver disease, should be discussed with a gastroenterologist.

Practical issues

Given the importance given to the clinical context, GPs must take care to review the patient’s history and use their clinical judgement to determine the need for further investigation, discussing the case with a specialist if appropriate.

Expert comment

Dr Jez Thompson, Bradford GP and the British Liver Trust/RCGP clinical champion for liver disease, said: ‘This recommends assessment pathways that are not part of routine general practice, but they would be fairly easy to embed in primary care systems. Liver disease is the only major cause of death with a rising incidence and primary care has a key role in identifying risk factors, and providing interventions.’

The guideline

British Society of Gastroenterology. Guidelines on the management of abnormal liver blood tests. London; BSG: 2017