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Liver disease

  

Liver disease doesn't usually cause any obvious signs or symptoms until it's fairly advanced and the liver is damaged.


ABNORMAL LIVER FUNCTION TESTS

Mild abnormalities of either ALT or ALP are common in general practice and may be transient, but appropriate investigation should not be overlooked as this may lead to missed opportunity for early intervention.  The commonest reasons are alcohol and fatty liver.  In the first instance, lifestyle issues (alcohol, diet, weight) should be addressed, medications reviewed and viral hepatitis should be excluded.  If liver enzymes remain abnormal after 3 months, a full liver screen is appropriate.  Consider referral to a hepatology clinic if multiple enzymes are raised, enzymes consistently twice the upper limit of normal or there is clinical concern of cirrhosis.

ADVICE

For advice, you can contact the HPB clinical nurse specialist at UHCW. Alternatively, you can bleep the Gastro SpR on call, who always carries bleep 4314. Or you can bleep Dr Esther Unitt, Consultant Hepatologist on bleep 4110. The number for her secretary (who is also Dr Wong’s secretary) is 02476 966089.

ALCOHOLIC LIVER DISEASE

Pre-referral investigations: FBC, LFT, GGT, ultra-sound abdomen

Offer contact details for the community alcohol team. Patients can phone the Recovery Partnership on 024 7663 0135.

Referral threshold: refer if alanine transaminase is twice upper limit of normal, otherwise surveillance in primary care, perhaps with LFTs every two months. Refer if any evidence of decompensation or if ultra-sound scan suggests cirrhosis. If jaundiced and still drinking, consider admission to hospital.

Patients who are jaundiced due to alcoholic liver disease are not suitable for the rapid access Jaundice Clinic. They should be referred to the hepatology clinic or admitted to hospital. If in doubt, please phone – contact details are at the top of this page.

FATTY LIVER

If fatty liver is suspected, address lifestyle (weight reduction and alcohol), lipids and diabetic control. Consider referral to hepatology if the alanine transaminase remains twice the upper limit of normal, Otherwise continue surveillance in primary care, with liver function tests every six months. The gamma GT may be elevated, but referral is unnecessary unless the other LFTs are abnormal.

GILBERT’S SYNDROME

Check LFTs. In Gilbert’s syndrome, only the bilbirubin will be raised. Request split bilirubin for confirmation. No need to refer unless there is diagnostic uncertainty. Consider if your patient could have haemolytic jaundice.

HAEMACHROMATOSIS

If you suspect haemachromatosis, please check family history.

Pre-referral investigations: LFT, ferritin, transferrin, ultra-sound abdomen

Referral threshold: refer all suspected cases. Screening and surveillance will be arranged by secondary care.

HEPATITIS AND JAUNDICE

Refer jaundiced patients directly to the Jaundice Clinic, tel 024 7696 6341, safe haven fax 024 7696 6090, otherwise refer to the Hepatology clinic (not the Acute Medical Clinic). If your jaundiced patient has alcoholic liver disease, please see the information near the top of this page.

If you need clinical advice, contact details are at the top of this page.

There is a referral form for the Jaundice Clinic which can be found in the right hand panel.

Isolated hyperbilirubinaemia (i.e. Gilbert’s syndrome) does not require referral.

All patients who are identified as Hepatitis B carriers (Hepatitis B sAg positive) should be referred to the hepatology clinic, regardless of liver function tests.

A positive hepatitis C antibody may reflect previous exposure to hepatitis C infection, rather than active viraemia. Check HCV RNA and refer to the hepatology clinic if positive, for consideration of anti-viral treatment.

WILSON’S DISEASE

Pre-referral investigations: for suspected cases, check ceruloplasmin, aminotransferase and ultra-sound abdomen

Referral threshold: refer all suspected cases and close family members

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