1. Diagnostic Pathway for Chronic Liver Disease
Print in colour 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

2. 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, p , Nov 2014.