Forum
Research
Managing abnormal liver
function tests
A practice audit led to clear guidance on dealing with abnormal liver function
tests in a primary care practice, writes Alan Barry
Managing abnormal liver function tests results is
an almost daily task for GPs around the country. Minor
abnormalities in otherwise healthy patients are regularly
discovered. How should we manage these abnormal blood
test results? When should we investigate this group of
patients and when should we refer them for a specialist
opinion?
My uncertainty prompted me to audit our surgery, and
how we had been managing newly discovered asymptomatic
patients with abnormal liver function tests.
British Society of Gastroenterology guidelines
On researching this area, I discovered the British Society
of Gastroenterology (BSG) guidelines for managing such a
group of patients. It is a document designed to help hospital physicians and GPs alike manage asymptomatic patients
with abnormal liver function tests. The document does not
include abnormalities of synthetic liver function tests,
namely albumin and INR.
It provides a suggested algorithm, which can be used as
a guideline in practice. A number of interesting points were
made in this document:
• A majority of asymptomatic patients with abnormal liver
function tests will have liver disease, and a proportion will
have significant disease
• Abnormal liver function tests in symptomatic and asymptomatic patients should be managed in a similar fashion
• Any degree of abnormality should be considered for investigation, as even minor abnormalities can be associated
with liver disease
• Abnormalities should be investigated if persisting for
more than six months.
The audit
With these guidelines in mind, I performed an audit in
our practice. Any patient with abnormal liver function test
results (bilirubin, aspartate aminotransferase (AST), alanine
aminotransferase (ALT), gamma glutamyltransferase (gGT)
Table 1
Algorithm for the management of abnormal LTFs
Clinical situation
Action suggested
Management suggested
Increased bilirubin
Recheck with conjugated bilirubin, exclude
haemolysis
Reassure as likely Gilbert’s syndrome
Increased gGT only
Alcohol advice, consider medications
Alcohol abstinence
Reassure – NO further investigations
Alkaline phosphatase and/or
AST/ALT > two times upper limit
of normal
1. Alcohol abstinence
2. Stop hepatotoxic drugs if possible
3. Advise weight loss if BMI > 25
4. Check gGT if only alkaline phosphatase
abnormal
5. Recheck in three to six months and if
persistently abnormal:
→Liver screen:
• Full history
• HbsAg
• HCVAb
• Alpha1 anti-trypsin
• Autoimmune profile
• Ferritin and transferrin saturation
• Copper and caeruloplasmin
→Ultrasound
Modified from BSG guidelines 2006 for the practice audit
FORUM March 2011 43
Liverfunctions/Barry/JMC./NH2* 1
01/03/2011 10:11:45
or alkaline phosphatase), who did not have symptoms
suggestive of liver disease, and who had not had an
abnormal result in the past, was included. I collected
data from July to November 2007. I analysed the charts
and kept a record of what management plans were put in
place to deal with these patients.
Following a discussion with the other GPs in the practice, we attempted to implement an algorithm, based on
the BSG guidelines, into our practice after the first arm
of the audit had been completed. In our practice, the
algorithm was modified slightly, such that any degree of
abnormality was included, and not just those that were
twice the upper limit of normal. With this new practice algorithm in mind, I subsequently collected data
on suitable patients between March and June 2008.
Again, only asymptomatic adults with ‘new’ abnormal
liver function tests were included.
Results
The total number of asymptomatic patients with
abnormal liver function tests between July and November 2007 was 25. When I reviewed the charts of these
patients, nine had a management plan in keeping with
the suggested algorithm by the BSG. Of the remaining
16 patients, 12 simply had isolated, abnormally raised
bilirubin levels.
After the attempted implementation into the practice
of the suggested algorithm for managing these patients,
14 patients between March and June 2008 were identified with new abnormal liver function tests. Of these
14, 11 were managed in accordance with our modified
algorithm.
Guidance
This was a small audit that will hopefully provide clear
guidance on dealing with this common scenario in our
practice. It is interesting to note how few ‘new’ abnormal liver function test results were seen during both
periods.
A large proportion of the results were isolated, mildly
elevated bilirubin levels. These were not further assessed.
Should we be keeping track of all of our patients with
mildly elevated bilirubin levels and arranging follow-up?
There were relatively few abnormal AST and ALT results.
The management of asymptomatic patients with abnormal liver function tests, in our practice, was largely in
accordance with the suggested BSG guidelines, both
before and after the algorithm was implemented.
I feel that the algorithm was easy to follow and allows
GPs to manage this commonly encountered situation
with some confidence, ensuring that liver disease is not
missed and also that appropriate referrals to hepatology
clinics are made.
It is, however, only a suggested algorithm. There are
a number of other recommendations on the management of abnormal liver function tests available. The BSG
guidelines, as they were easy to read and had a suggested
algorithm, were chosen and adopted for the purpose of
this audit in our practice.
Alan Barry is in practice in Blackrock, Co Dublin
For the full BSG guidelines on abnormal LFTs see:
www.bsg.org.uk/pdf_word_docs/ablft_draft05.doc
Liverfunctions/Barry/JMC./NH2* 2
02/03/2011 09:04:46