REMEDY : BNSSG referral pathways

Chronic Liver Disease

Checked: 29-11-2017 by Rob.Adams Next Review: 29-11-2018

Principles of Management

Abnormal LFTs are a common finding in general practice. Local pathways have been developed by Dr Kate Rush (GP) with support of local hepatologists to guide GPs on how to investigate and manage patients and when to refer:

Chronic Liver Disease Diagnostic Pathway - for patients drinking over 14 units of alcohol per week.

Non-Alcoholic Fatty Liver Disease Diagnostic Pathway - for patients drinking 14 units of alcohol per week or less.

Enhanced Liver Fibrosis (ELF) test is a more specific marker of fibrosis in NAFLD. It is not yet available locally but should be available soon on ICE.

Fibrosis-4 (FIB-4) is a calculation using age, AST, ALT, platelet count. Click on the link for a calculator. Labs may report this in future.

AUDIT - screening tool for alcohol misuse/ dependence (Patient.co.uk)

Please also note the following advice:

  • There is no need to repeat an abnormal Liver Function Test once you have had one abnormal result  – please follow the appropriate pathway given the patients alcohol consumption

  • There is no need to re-check Liver Function once a patient has started a statin (this is advice from local clinicians although UKMi guidelines still suggest they should be repeated at 3 months and 12 months - clarification to follow).

  • All ICE panels will be the same for requesting a Non Invasive Liver Screen across BNSSG

The Bristol Referral Service will triage referrals to secondary care against these pathways and may return referrals where management in primary care is considered appropriate.

Patient information can be found on the British Liver Trust website.

Referral Guidance

In patients with jaundice or ALT> 5 times normal then consider 2WW Referral for suspected pancreatic cancer

If viral serology is positive for hepatitis then refer to Hepatology (viral) via e-referral.

Fibroscan is not currently available directly (but this may change soon) and patients should therefore be referred to hepatology (non-viral) via e-referral to access this via the clinic who will arrange appropriate follow up if necessary.

Please use the attached referral forms as appropriate when referring:

Hepatology Referral Form

Fibroscan Referral Form

There is also the NBT Urgent Hepatology Service for patients who meet their referral criteria

 

Red Flags

In patients with jaundice or ALT> 5 times normal then consider 2WW Referral for suspected pancreatic cancer

Abnormal LFTs associated with the following should be considered for 2WW referral:

  • Painless jaundice

  • Weight loss

  • Anaemia

  • DVT/PE

  • USS showing dilated intrahepatic ducts

  • Steatorhoea

  • Upper back pain

Useful Links

ROADS - link to local referral details for alcohol support and detox.

FRAMES - advice on giving brief alcohol intervention (CKS)

AUDIT - screening tool for alcohol misuse/ dependence (Patient.co.uk)

Drinkaware - link to advice and leaflets for patients and health professionals.

South Gloucestershire Drug & Alcohol Service - a link to the service's website.

Patient Information

Fatty Liver Disease - Patient.co.uk

Abnormal Liver Function Tests - Patient.co.uk

British Liver Trust

LFTS Explained

Non-alcohol Related Fatty Liver Disease

Alcohol & Liver Disease

Diet & Liver Disease