Transcript 7 - Ipswich and East Suffolk CCG

Deranged LFTs
Pathways
Dr A H Mohsen
MD (KCL),
MRCP, DTM&H
A H Mohsen
Consultant 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
Gastroenterology 2002

Those who have LFTs check: >10 are
above twice limit of normal
abnormal test result resolve
spontaneously in 38% of patients
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
81 no definable cause had LB
Cause
Number
Steatosis
41
NASH
26
Fibrosis
4
Hepatitis B
3
Cirrhosis
2
Normal
8
Am J Gastroenterol 1999
Abnormal LFTs
Isolated rise Bili
up to 3x ULN
exclude haemolysis and
Conjugated bilirubin
Probably Gilbert’s
ALT/AST
Raised ALK-P
Abnormal LFTs
Isolated rise Bili
up to 3x ULN
ALT/AST
Raised ALK-P
Check GGT
Normal:
Bone disease
Raised: x2 ULN
>3 months
USS & AMA
Normal: repeat in 3-6 months
Trend not improving
abnormal:
refer
ALT/AST
ALT<100
100-400 mod Risk
Review 1-3 /12
Review 1 months
Normal
No further action
ALT>400
Raised: x2.5 ULN
>3 months
Hep A,E,CMV,EBV
USS, liver screen
USS & liver screen
Referral to Gast
USS & liver screen
Negative screen
Fat on USS
Positive screen
No fat on USS
Treat diagnosis
NAFLD + ETOH
Referral to Gast
Fatty liver (NAFLD/NASH)
Fibro-scan
<7
>7
Criteria
Low risk
High risk
Age
<45
>45
Diabetes/IFG
Absent
Present
BMI
<30
>30
AST/ALT
<1
>1
Platelet count
>150
<150
Albumin
>34
<34
If > 3 criteria
• Life style intervention
• Repeat fibro-scan in
1-2 years
• GP to monitor
Referral to Gast
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
fibro-scan > 7
USS & fibro-scan
If trends worsening
fibro-scan > 7
Refer to Gast
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.
2.
3.
4.
5.
6.
7.
NovoRapid 20-40 units pre meal
Lantus 40 units pre bed
Metformin MR 1g bd
Bendroflumethiazide 2.5mg
Omeprazole 5mg
Diltiazem MR 90mg
Irbesartan 75mg
Ref.
Range
12/03/2014
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
22/09/2011 02/11/2010 27/10/2008 31/01/2007
NAFLD prevalence


Liver biopsy/post-mortem series
Hultcrantz R 1986, Ground K 1982
 15-39%
Third of the population was found to have
hepatic steatosis in US (MRI)
Hepatology 2004; 40:1387



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
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.
Project Overview
A 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