ABNORMAL LFT PROTOCOL (updated 2008)

Jaundice or elevated bilirubin? ALT and Alk phos Albumin all normal? Investigate according to GILBERT PR T ! L

Patient ill or bilirubin " #$$?

A%&IT A!'TEL( or %I)!')) *+,

Bilirubin -$$.#$$?

Phone or /a0 consultant gastro /or urgent clinic visit *+, !heck 2ep A3B serolog45 re/er *+,

Bilirubin 1-$$?

Elevated alk phos?

6ormal ALT and GGT?

B 6(7

Alk Phos protocol ALT " 8$ RE9ER

6ot ill 6ormal alk phos ALT 1 8$ 6ot :aundiced

GP to investigate according to TRA6)A&I6A)E PR T ! L

*+, ;hen re/erring :aundiced patients please provide a detailed drug histor4 *including all prescriptions issued <ithin the preceding three months, and also full results o/ all investigations per/ormed= n this basis <e can decide on urgenc4 re>uired= &ost5 but not all5 :aundiced patients <ill be allocated to urgent appts=

GILBERT PROTOCOL
Isolated hyperbilirubinaemia This is usuall4 Gilbert?s s4ndrome= !heck@ L9Ts5 con:ugated v uncon:ugated bilirubin5 haemoglobin5 reticuloc4te count= !riteria Bilirubin /luctuates but 1A$= *)ome Gilberts patients go 4ello<er than this but the4 are probabl4 <orth investigating more care/ull4@ REFER or DISCUSS=, Bilirubin <ill be higher i/ patient /asting or during intercurrent illness= Ask /or con:ugated v= uncon:ugated bilirubin@ the h4perbilirubinaemia should be largel4 uncon:ugated5 but don?t trust the laborator4 ranges /or con:ugated bilirubin5 the4 are too strict5 and man4 Gilberts patients have an elevated con:ugated bilirubin= 6ormal 9B! and reticuloc4te count *to e0clude haemol4tic anaemia,= I/ the patient is <ell and meets all the above criteria5 reassure and e0plain the diagnosis= Give in/ormation lea/let= The patient does not need an u3sound or re/erral=

TRANSAMINASE PROTOCOL
&ost patients <ith persistentl4 elevated ALT have /att4 liver disease due to alcohol B3. obesity B3. diabetes B3. hyperlipidaemia

STEP 1
!are/ul alcohol histor4= I/ intake " -Cu3<eek encourage the patient to abstain completel4= !are/ul drug histor4= )top an4 medications that ma4 be relevant= Think about causes o/ /att4 liver@ diabetes5 obesit45 e0cess alcohol= === then recheck the L9Ts in D.C <eeks=

STEP 2 If transaminases ! "# normal proceed to Step 2 $ " in%# and refer If transaminases & "# normal then '((
rganise the /ollo<ing bloods E GP revie<@ ;eigh the patient and calculate B&I= *B&I"#F is abnormal and disease.associated=, !heck BP 9asting chol@2%L E Trigs5 9asting Blood )ugar5 9B! and Gamma GT GP Revie< - <eek later I/ alcohol or /att4 in/iltration likel4 then support li/est4le changes and re.check a/ter D months= I/ not or i/ the l/ts have not resolved a/ter the D months o/ li/est4le changes then arrange the /ollo<ing investigations and consider re/erral@

STEP "
2ep B and 2ep ! serolog4 Autoantibodies including TTG5 A&A5 A)&5 A69 9erritin5 Alpha.-.antitr4psin !aeruloplasmin i/ patient aged under DF4 T9T I6R I/ ALT persistentl4 more than t<ice normal consider liver ultrasound= 6ote . not ever4one needs an ultrasound7

Fatty )i%er
&ake a diagnosis o/ fatty li%er disease i/@ 2epB5 2ep!5 /erritin5 alpha.-.antitr4psin *and caeruloplasmin i/ age1DF, are normal 6egative TTG5 A695 antimitochondrial and smooth muscle antibodies 6ormal platelet count and I6R 6ormal albumin There is a reasonable cause such as obesit45 alcohol5 diabetes5 h4perlipidaemia I/ ultrasound per/ormed5 there should be no splenomegal4 and the liver should be either G/att4H *echogenic, or normal Transaminases are belo< 8$ and there is no progressive deterioration= Address risk /actors such as alcohol5 obesit4= Treat an4 concurrent conditions such as diabetes and h4pertension and h4perlipidaemia= Recheck L9T in D.C months= Re/erral is not usually necessary e#cept

if they are obese5 age"CF <ith 6I%%& *as these patients are at higher risk o/ 6A)2 and progression to cirrhosis,=

Alkaline P !"p ata"e P#!t!$!l

-= #= D= C= I/ alk phos rasied check l/ts E gamma gt= I/ abnormal then re/er '))5 and consider Antimitochondrial antibodies5 )mooth &uscle Antibodies and Immunoglobulins= I/ l/ts and gamma GT normal check PT2 and ad:usted calcium= I/ these are normal then@ I/ alk phos 1 -=F 'pper Limit o/ 6ormal *'L6, re.check in - month= Ialues up to #$J over 'L6 are likel4 to be statistical rather than clinical KabnormalsK= I/ on repeat " -=# 0 'L6 then arrange alk phos isoenL4mes and i/ o/ bon4 origin consider P)A in men5 !MR in smokers5 breast e0am in <omen5 9B! E E)R B3. m4eloma screen and don?t /orget Pagets disease in the elderl4= I/ alkaline phosphatase "# 'L6 *on a single measurement, then /urther investigation E probable re/erral is indicated=

F=

STATINS AN% LFT"

It remains appropriate to check L9Ts on patients prior to commencing a statin I/5 a/ter /ollo<ing the above protocol5 the diagnosis is that o/ /att4 liver disease@ o It is sa/e to start the statin o The patient does not need to be re/erred speci/icall4 /or this reassurance o The L9Ts do not need to be checked /urther 9urthermore5 the results /rom the large 2eart Protection )tud4 trial using simvastatin suggest that@ there is no need for routine liver function checks when using this regimen or other statin regimens with similar safety data from large-scale randomised trials

Derived from the 2002 protocol by Dr G Sobala !onsultant "hysician #uddersfield $oyal %nfirmary& 'pdated using recent ()* publications + G" notebook 200, by the Sunny(ank )-! G"s&
'se/ul re/erences B&J #$$-ND##@DD.DO AB! o/ diseases o/ liver5 pancreas5 and biliar4 s4stem B&J #$$ONDDD@C8-.C8D *# )eptember,5 doi@-$=--DO3bm:=DDD=AFOO=C8- Cases in primary care laboratory medicine Biochemical Pliver /unction testsP