Shaping better health
REMEDY : BNSSG referral pathways

Chronic Liver Disease

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

Principles of Management

In patients with abnormal LFTs please see the Abnormal LFTs section of Remedy for initial advice.

If chronic liver disease is suspected please use local pathways that 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.

Please review Red Flags and consider 2WW or Urgent Hepatology referral (see Red Flag section below). If there are no Red Flags then please use the appropriate pathway:


Further advice on investigations:

NILS (Non-Invasive Liver Screen) - see NAFLD pathway above for details on what should be checked (should also available as a profile on local ICE systems).

USS requests - Requests for USS as a part of NILS should be done prior to referral. USS requests should include details on indication for request- see USS guidelines for further information on appropriate requests.

Fibrosis-4 (FIB-4) is a calculation using age, AST, ALT, platelet count. Click on the link for a calculator. This can now be requested on ICE.

Enhanced Liver Fibrosis (ELF) test is a more specific marker of fibrosis in NAFLD.  GPs should be able to request this on ICE at UHB but it may not be universally available at other labs.

AUDIT - screening tool for alcohol misuse/ dependence (

Please also note the following advice:

  • There is no need to repeat an abnormal Liver Function Test once you have had one abnormal result (except in patients with jaundice)  – please follow the appropriate pathway above depending on the patient's alcohol consumption.

  • Local hepatologists and BSG guidelines advise that there is no need to re-check LFTs once a patient has started a statin as drug induced liver disease is rare. However, please be aware that other guidelines (UKMi and BNSSG formulary - lipid guidance) still suggest they should be repeated at 3 months and 12 months.

  • All ICE panels should be the same for requesting a Non Invasive Liver Screen (NILS) across BNSSG.


The BNSSG 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

Suspected Cancer

In patients with red flags consider 2WW Referral for suspected pancreatic cancer

Viral Hepatitis

If viral serology is positive for hepatitis then refer to Hepatology via eRS - see the Viral Hepatitis section for further information.


If fibroscan is indicated then this can be requested in the following ways: 

  • NBT - refer to the NBT Hepatology Fibroscan Clinic via eRS (this direct service is for patients with alcohol misuse only).
  • UHB - refer to Hepatology Clinic via eRS requesting fibroscan only and if possible enclosing the Fibroscan Referral Form.

Hepatology Clinics (non-viral)

If Hepatology (non-viral) referral is indicated as directed by the pathways above, then please refer via eRS. Please make sure all components of a NILS have been completed prior to referral (including USS liver) and fibrosis test (fibroscan or ELF) if indicated.

For UHB you can use the optional UHB Hepatology Referral Form.

Urgent Hepatology Clinics

NBT. The  NBT Urgent Hepatology Service is for patients who meet their referral criteria

UHB. Mark referral urgent (BNSSG  Referral Service has been reassured that letters are triaged by the hepatologists and patients seen appropriately).


Red Flags

See the Suspected Pancreatic Cancer Pathway for details of red flags and how to refer.

Patients with a history of jaundice, weight loss and signs of malignancy are at high risk of malignancy and should be referred via 2WW for suspected cancer. An USS on the next working day should also be requested.

There is also the NBT Urgent Hepatology Service for patients who meet their referral criteria which include decompensated cirrhosis, ALT over 1000, bilirubin over 100 or UHB will also see patients urgently if indicated.

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 (

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 -

Abnormal Liver Function Tests -

British Liver Trust

LFTS Explained

Non-alcohol Related Fatty Liver Disease

Alcohol & Liver Disease

Diet & Liver Disease