Diagnostic Pathway for Chronic Liver Disease Print in colour 06 10 16 v5 Severe Liver Disease ALT > 5x normal – jaundice or persistent low albumin AND low platelets Unusual LFT’s Slight to moderate increase in ALT / ALP / AST or GGT; drug history Suspected alcohol risk NB 2WW Check viral serology and autoimmune profile – refer if positive Consider referral to ROADs for support with alcohol if indicated and give alcohol harm reduction advice (FRAMES). Consider thiamine and vitamin B supplements. Liver referral AUDIT C to stage alcohol risk AUDIT C score <5 AUDIT C score ≥ 5 ALT, AST +/- GGT raised Brief alcohol intervention repeat LFTs if they were abnormal, review in 3-12 weeks < 3 metabolic syndrome risk factors, repeat test, if still abnormal ALP elevated, ultrasound to exclude biliary obstruction, repeat tests if still abnormal, consider isoenzymes Check for metabolic syndrome risk factors: Central obesity; High triglyceride; Hypertension; Low HFL cholesterol; High Glucose or T2DM Advise weight loss and exercise, assess AST/ALT ratio Repeat AUDIT C; full 12 item WHO AUDIT questionnaire if positive AUDIT = hazardous or harmful even if LFTs normal Check ferritin and refer for fibroscan LFTs remain elevated AST/ALT < 1.0 AST/ALT > 1.0 Alcohol risk and LFTs both resolved Fibroscan < 8 with good IQR Does not exclude early liver disease, repeat pathway in 3-5 years if risk factors remain AUDIT=harmful, , beware false re-assurance, further interventions or refer alcohol services Fibroscan 8-16 Progressive liver fibrosis, further investigation needed - hepatology referral unless there is alternative liver expertise Fibroscan ≥ 16 New diagnosis or cirrhosis, refer hepatology, check OGD for varices

Key Blue – Primary Care Green – No evidence of significant liver fibrosis. Address risk factors and report after referral if they remain Purple– Secondary Care referral usually indicated for probable progression liver fibrosis but not cirrhosis Red – Referral to secondary care for probable serious liver disease, acute hepatic injury, severe fibrosis or cirrhosis Reference: Addressing liver disease in the UK: A blueprint for attaining excellence in healthcare and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity and viral hepatitis. The Lancet, Vol 384, No 9958, p1953-1997, Nov 2014.