1. Asymptomatic Abnormal LFTs NHS Lothian guideline
Dr Sara Jenks
Clinical biochemistry registrar

2. NHSL LFT guidelines Based on local expert consensus Contents:
Summary flow diagram for ALT/ALP/GGT
Flow diagram for isolated rise in bilirubin
Statins & abnormal LFTs
Hepatotoxic drugs list

4. Asymptomatic abnormal ALT, GGT
or ALP result
Suggested thresholds for investigation when elevated on at least 2 occasions >4 weeks apart:
ALT > 70
ALT with an abnormal GGT/ALP
(If isolated ALT check Hep B&C serology only)
GGT >100
ALP >200 with an abnormal GGT
(If ALP raised in isolation investigate for bone disease)

5. (NB: If ALT/ALP/GGT persistently abnormal but below thresholds consider repeat LFTs in 1 year.
If still abnormal use clinical judgment and consider further investigation even if remains below thresholds)

6. Patient assessment
History
Examination
Liver screen including liver ultrasound
Medication review
If alcohol suspected, advise abstinence

7. Caerulopasmin (if <55 years)
Liver Screen
Abdominal Ultrasound
FBC
LFTs
Caerulopasmin (if <55 years)
Ferritin (check Transferrin sats if ferritin raised)
Hepatitis serology – HBsAg, anti-HCV Ab
Immunology – Anti-smooth muscle Ab, anti-nuclear Ab, anti-mitochondrial Ab
Glucose
Cholesterol
Albumin
INR
AST:ALT ratio
Igs removed at GP request – felt to cause problems/not be that helpful.
?role for checking TFTs

8. GI referral criteria*
Diagnostic tests suggest any cause other
than alcohol or NAFLD
Evidence of impaired liver function:
↑bilirubin (not due to Gilberts syndrome)
↑ INR,
↓albumin
Evidence of advanced fibrosis/cirrhosis
AST:ALT ratio > 0.8
Platelets < 150
Splenomegaly
ALT persistently >200
Diagnosis or management still uncertain

9. If the referral criteria have not been met then:
The abnormal LFTs are likely to be due to either NAFLD or alcohol and there is nothing to indicate advanced fibrosis/cirrhosis
These patients can continue to be safely managed in primary care with appropriate advice e.g. diet, exercise, alcohol abstinence

10. If the referral criteria have not been met then:
A small number will go on to develop cirrhosis if they do not make the appropriate lifestyle changes.
At present we are unable to identify which people are most likely to progress and ongoing screening for the development of fibrosis is not currently available in primary care
A yearly check of LFTs and AST:ALT ratio with reinforcement of lifestyle advice is probably appropriate