Deranged LFTsPathways

A H MohsenDr A H Mohsen

MD (KCL), MRCP, DTM&HConsultant Gastroenterologist

Main causes for progression of liver

disease

Alcohol consumption Obesity Hepatitis B/C

Common serum liver chemistry tests

AST/ALT Hepatocellular damage

Bilirubin Cholestasis, impaired conjugation, or biliary obstruction

GGT Cholestasis or biliary obstruction

Alk-P Cholestasis, infiltrative disease, or biliary obstruction

PT/Albumin Synthetic function

How common abnormal LFTs?

Abnormal LFTs: 1%–4% of the asymptomatic population

Those who have LFTs check: >10 are above twice limit of normal

abnormal test result resolve spontaneously in 38% of patients

Gastroenterology 2002

Ryder, BMJ 2001

149 asymptomatic patients with elevated alanine aminotransferase levels who

underwent liver biopsy

Cause %

Fatty live 56

Non-A, Non-B hepatitis 22

Alcohol related 11

Hepatitis B 3

Other diagnosis 8

No cause 2

Scand J Gastroenterol 1986

1124 consecutive patients with chronic elevations in aminotransferase levels

Cause Number

Steatosis 41

NASH 26

Fibrosis 4

Hepatitis B 3

Cirrhosis 2

Normal 8

Am J Gastroenterol 1999

81 no definable cause had LB

Abnormal LFTs

Raised ALK-PALT/ASTIsolated rise Bili up to 3x ULN

exclude haemolysis andConjugated bilirubin

Probably Gilbert’s

Abnormal LFTs

Raised ALK-PALT/ASTIsolated rise Bili up to 3x ULN

Check GGT

Raised: x2 ULN>3 months

Normal:Bone disease

USS & AMA

abnormal:refer

Normal: repeat in 3-6 monthsTrend not improving

ALT/AST

ALT>400100-400 mod RiskALT<100

Review 1 months

Raised: x2.5 ULN>3 months

Hep A,E,CMV,EBVUSS, liver screen

USS & liver screen Referral to Gast

Review 1-3 /12

No further action

Normal

USS & liver screen

Positive screenNegative screen

Treat diagnosis

Referral to Gast

Fat on USS

NAFLD + ETOH

No fat on USS

Fatty liver (NAFLD/NASH)

Fibro-scan

Referral to Gast

> 7

Criteria Low risk

High risk

Age <45 >45Diabetes/IFG

Absent Present

BMI <30 >30AST/ALT <1 >1Platelet count

>150 <150

Albumin >34 <34If > 3 criteria• Life style intervention• Repeat fibro-scan in 1-2 years• GP to monitor

< 7

Isolated elevation of GGT

Levels > 3 times upper limit of normal:Repeat in 3 monthsAlcohol intake adviceReview medicationsIf trends worsening

USS & fibro-scan

Levels < 3 times upper limit of normal:Monitor 6-12 monthlyAlcohol intake adviceReview medications

Refer to Gast

fibro-scan > 7

fibro-scan > 7

Recent case ST, 62 male Presented in March with severe UGIB

Stabilised OGD: Likely gastric varices (D/W

Addenbrokes) Catastrophic variceal bleed 10 hours later

Died PMH:

Type II DM (1999) Hypertension IHD

ST, 62 male Current medications:

1. NovoRapid 20-40 units pre meal2. Lantus 40 units pre bed3. Metformin MR 1g bd4. Bendroflumethiazide 2.5mg5. Omeprazole 5mg6. Diltiazem MR 90mg7. Irbesartan 75mg

Ref.Range

12/03/2014 22/09/2011 02/11/2010 27/10/2008 31/01/2007

ALP (30 - 130) 105  359  328  297  228 

Albumin (35 - 50) 31  38  40  46  41 

ALT (0 - 41) 37  74  88  93  78 

Total Bilirubin

(0 - 20) 22  18  21  13  14 

NAFLD prevalence Liver biopsy/post-mortem series

15-39% Third of the population was found to have

hepatic steatosis in US (MRI)

Obese persons NAFL 60-90%, NASH 20-25%, cirrhosis 2-

3% Diabetic : 50 % Morbidly obese and diabetic person

NAFL 100%, NASH 50%, cirrhosis 19%Dixon J 2001, silverman J 1989, 1990

Hultcrantz R 1986, Ground K 1982

Hepatology 2004; 40:1387

Examination ProcessA mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound.The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis. - the stiffer the liver is the greater the degree of fibrosis.

Project OverviewA novel diagnostic pathway to detect significant liver disease in the community

Amount Won £100,000

Innovation Challenge Prize Winner, November 2013

Summary

Clear pathways NAFLD is the most common cause 1/3 of deranged LFTs resolve

spontaneously Identify those at risk and refer

early