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Deranged LFTs Pathways

Deranged LFTs Pathways. A H Mohsen. Dr A H Mohsen MD (KCL), MRCP, DTM&H Consultant Gastroenterologist. Main causes for progression of liver disease. Alcohol consumption Obesity Hepatitis B/C. Common serum liver chemistry tests. How common abnormal LFTs?.

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Deranged LFTs Pathways

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  1. Deranged LFTsPathways A H Mohsen Dr A H Mohsen MD (KCL), MRCP, DTM&H Consultant Gastroenterologist

  2. Main causes for progression of liver disease • Alcohol consumption • Obesity • Hepatitis B/C

  3. Common serum liver chemistry tests

  4. 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

  5. 149 asymptomatic patients with elevated alanine aminotransferase levels who underwent liver biopsy Scand J Gastroenterol 1986

  6. 1124 consecutive patients with chronic elevations in aminotransferase levels 81 no definable cause had LB Am J Gastroenterol 1999

  7. Abnormal LFTs Isolated rise Bili up to 3x ULN ALT/AST Raised ALK-P exclude haemolysis and Conjugated bilirubin Probably Gilbert’s

  8. Abnormal LFTs Isolated rise Bili up to 3x ULN ALT/AST Raised ALK-P Check GGT Raised: x2 ULN >3 months Normal: Bone disease USS & AMA Normal: repeat in 3-6 months Trend not improving abnormal: refer

  9. ALT/AST ALT<100 100-400 mod Risk ALT>400 Review 1 months Review 1-3 /12 Raised: x2.5 ULN >3 months Hep A,E,CMV,EBV USS, liver screen Normal No further action USS & liver screen Referral to Gast

  10. USS & liver screen Negative screen Positive screen Fat on USS No fat on USS Treat diagnosis NAFLD + ETOH Referral to Gast

  11. Fatty liver (NAFLD/NASH) Fibro-scan < 7 > 7 If > 3 criteria • Life style intervention • Repeat fibro-scan in • 1-2 years • GP to monitor Referral to Gast

  12. Isolated elevation of GGT Levels < 3 times upper limit of normal: Monitor 6-12 monthly Alcohol intake advice Review medications Levels > 3 times upper limit of normal: Repeat in 3 months Alcohol intake advice Review medications If trends worsening USS & fibro-scan fibro-scan > 7 fibro-scan > 7 Refer to Gast

  13. 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

  14. ST, 62 male • Current medications: 1. NovoRapid 20-40 units pre meal 2. Lantus 40 units pre bed 3. Metformin MR 1g bd 4. Bendroflumethiazide 2.5mg 5. Omeprazole 5mg 6. Diltiazem MR 90mg 7. Irbesartan 75mg

  15. NAFLD prevalence Hultcrantz R 1986, Ground K 1982 • 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% Hepatology 2004; 40:1387 Dixon J 2001, silverman J 1989, 1990

  16. Examination Process A 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.

  17. Project Overview A novel diagnostic pathway to detect significant liver disease in the community Amount Won £100,000 Innovation Challenge Prize Winner, November 2013

  18. Summary • Clear pathways • NAFLD is the most common cause • 1/3 of deranged LFTs resolve spontaneously • Identify those at risk and refer early

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