Abnormal LFTs – when do I need to consider chronic liver disease
Dr Edward Fogden
Consultant Gastroenterologist SWBH
30th January 2014
Learning objectives
• Elevated LFT vs liver disease
– Why it matters / common referral to gastroenterology Approach to patient with elevated Liver tests
• Approach to patient with elevated Liver tests
– History, examination and lab features of chronic liver disease
liver disease
• Core conditions
– Fatty Liver
– Alcohol
– Viral Hepatitis
Liver disease - cirrhosis
• Prevention
– earlyy identification of risk factors
• Main causes of cirrhosis are modifiable
– Alcohol
Al h l
– Obesity / metabolic syndrome
– Viral hepatitis (B, C)
Approach to increased LFT
• History
– Alcohol; viral hepatitis risk factors; medications
i l di h
including
herbal
b l / alternative
lt
ti
• E
Examination
i ti
– BMI
– Can
C b
be normall examination
i i iin compensated
d cirrhosis
i h i
– Features of decompensated cirrhosis
• Blood tests
– INR, LFT, FBC
– ALT elevation not guide to underlying liver disease on
its own
Clinical
features
off
cirrhosis
Basic approach
Basic approach
• History
– Alcohol; viral hepatitis risk factors
– medications including herbal / alternative
• Examination
– Features of cirrhosis
• Blood tests
– INR, LFT, FBC, UE
• Degree of ALT elevation not guide to underlying liver disease on its own
– Significant blood results – bilirubin, INR, PLT, Alb
– Full screen
Full screen
• Liver screen
– Hepatitis B, C serology
– Immunoglobulins
– Ferritin / iron studies
– Autoantibodies • AMA, liver kidney, smooth muscle, ANA
– Caeruloplasmin, TTG
l l
• Address modifiable risk factors
– DM, weight, alcohol, cholesterol
• Ultrasound
Case 1
Case 1
•
•
•
•
•
•
57yr female
57
f
l
“Well‐woman” clinic – cholesterol 7.3
Diabetic BMI 30 drinks <10 units alcohol / week
Diabetic, BMI 30, drinks <10 units alcohol / week
Family history of ischaemic heart disease
Started on simvastatin 40mg/d
Started on simvastatin 40mg/d
LFTs one month after commencing statin:
– Bilirubin 7, ALT 75, ALP 125, albumin 40, GGT 65, INR 1
Bilirubin 7, ALT 75, ALP 125, albumin 40, GGT 65, INR 1
• What are the abnormalities?
• What is the likely diagnosis?
y g
• What should you do next?
•
•
•
•
•
•
57yr female
57
f
l
“Well‐woman” clinic – cholesterol 7.3
Diabetic BMI 30 drinks <10 units alcohol / week
Diabetic, BMI 30, drinks <10 units alcohol / week
Family history of ischaemic heart disease
Started on simvastatin 40mg/d
Started on simvastatin 40mg/d
LFTs one month after commencing statin:
– Bilirubin 7, ALT 75, ALP 125, albumin 40, GGT 65
Bilirubin 7, ALT 75, ALP 125, albumin 40, GGT 65
• What are the abnormalities? (raised ALT, GGT)
• What is the likely diagnosis?
y g
((“fatty liver”)
y
)
• What should you do next? NAFLD
•
•
•
•
Hepatic manifestation of metabolic syndrome
Commonest cause of raised LFT in west
40‐70% of type 2 DM
Steatosis  NASH  fibrosis  cirrhosis
– 1‐2% develop cirrhosis over 15‐20 years
– 12% chance of NASH & fibrosis  cirrhosis over 8 years
• Risk
Risk factors:
factors:
– Insulin resistance, increasing age, obesity, smoking
Approach to NAFLD
Approach to NAFLD
•
•
•
•
History – alcohol, risk factors Examination
Blood tests & liver screen
Management
– Use of scoring systems eg Angulo to decide on risk of fibrosis / scarring & guide referral / need for fibroscan
– Fibroscan
b
– Modifiable (cardiovascular) risk factors • DM, lipids, weight
– Little evidence for medications; metformin has been used
Fibroscan at Fibroscan
at
SWBH
FibroScan ‐ Rationale
Case II
Case II
•
•
•
•
45 year old male
Presents with jaundice and raised ALT
Presents with jaundice and raised ALT
Jaundice on examination
Previously drank 6L 7.5% cider per day
– Recently stopped as unwell
Recently stopped as unwell
• Lost job and driving licence due to alcohol
• Bilirubin 120, ALT 55, INR 1.7
Alcohol
• Significant problem
– Increasing deaths related to alcohol
g
• Birmingham / Sandwell
– 15%
15% / 16% increasing risk drinkers (£50m)
/ 16% i
i
i k d i k (£50 )
– 4% high risk (£12.5m)
– 1000 admissions per year to SWBH directly related to alcohol / 3500 partly.
/
p y
– Overall costs £400m / year to Birmingham
• Deprivation & alcohol
Deprivation & alcohol
Alcohol & inequalities
Alcohol & inequalities
• Lower socioeconomic groups are over p
represented in non drinkers and heaviest drinkers; suffer the most harm
– Most
Most deprived 20% of population affected 2‐5 deprived 20% of population affected 2‐5
fold (admissions, mortality)
– men >35, unskilled/manual/unemployed
>35
kill d/
l/
l d
– 50% homeless dependent on alcohol
Liver disease due to alcohol
Liver disease due to alcohol
• Various presentations:
– Fatty Liver (raised LFT, fatty liver, normal INR etc)
– Alcoholic hepatitis (jaundice, coagulopathy)
– Cirrhosis
• Early identification of increasing risk and high risk drinkers key
– Change in behaviour / reduce or stop alcohol
– Aim to reduce the long‐term harm to health
• Abstinence from alcohol cornerstone of treatment of alcoholic hepatitis and cirrhosis
• Refer jaundiced / unwell / signs of cirrhosis / clinical concern
• SWBH Alcohol care team
– Think Alcohol screening programme
• Assess +/‐ brief advice or referral • Community alcohol services
• Swanswell
• Aquarius
• Community alcohol matrons
• Young peoples and family services
• Primary care alcohol screening, brief advice or referral key
– Swanswell – 0845 112 0100
– Aquarius – 0121 414 0888
Scenario 3
Scenario 3
• 50yr Asian male (born in Pakistan)
• Presents with lethargy, no alcohol, non‐diabetic, slim
• Routine bloods:
– Normal FBC, TSH, glucose
Normal FBC, TSH, glucose
– LFTs: bilirubin 10, ALT 90, ALP 125, albumin 38
• What are the abnormalities?
What are the abnormalities?
• What diagnoses need to be considered?
Hepatitis B
Hepatitis B
• Major
Major cause of morbidity / mortality globally:
cause of morbidity / mortality globally:
– Most chronic hepatitis B is acquired early in life
– 1:20 worldwide – 95% of new cases of chronic HBV in UK imported
f
f h
d
• Screening high risk groups
– Migrant groups
g
g p
– Injecting drug users
– Men who have sex with men
– Unprotected sex
U
t t d
– Immigration detainees
– Babies of mothers with Hep B / C, prisoners, children care homes
p / ,p
,
– People with infected partners
• Key intervention is to vaccinate close contacts of HBV positive persons eg: neonates born to HBV positive mums
persons eg: neonates born to HBV positive mums
Hepatitis B
Hepatitis B
• P
Prognosis in young patients is unpredictable, therefore often i i
i
i
di bl h f
f
unclear whom to treat
• All patients with a positive surface antigen should be referred All patients with a positive surface antigen should be referred
for assessment
– Urgent referrals for pregnant or unwell
• Groups at risk of disease progression identifiable:
– Male
– Age > 40y
Age > 40y
• 8‐20% risk of cirrhosis over 5 years, 1 in 10 will develop cancer
Hepatitis C
Hepatitis C
• 215,000 in UK, 1500‐3000 locally
l ll
• Increasing number of admissions and deaths due to end stage liver disease from Hep C
p
• Risk factors
– 90% ‐ Injecting drug use (50% unaware)
– Migrants from Asia, E & S Europe, & countries with prevalence >2%
– Men who have sex with men
– Homeless
– Blood products pre 86, transfusions pre 91
– Medical / dental work overseas
/
– Babies of mothers with Hep B / C, prisoners, children care homes
– People with infected partners
Hepatitis C Natural history
Hepatitis C Natural history
Infection
8 weeks
Hepatitis
Fulminant liver
failure
Jaundice
Asymptomatic
10%
clearance
10-30
years
90%
Cirrhosis, liver failure, liver cancer
Hepatitis C
Hepatitis C
• Only 10% spontaneously clear virus:
– 20‐30% get cirrhosis over 20 years, of whom some get liver cancer
Long period of ‘good
good health
health’
• Long period of • NICE recommends treatment (IFN‐α / ribavirin)
• Newer drugs now licensed with higher rates of Ne er dr gs no licensed ith higher rates of
sustained virological response – awaiting NICE
• Refer all patients with hepatitis C to a viral hepatitis specialist
Learning objectives
Learning objectives
• Elevated LFT vs liver disease
– Why it matters / common referral to gastroenterology Approach to patient with elevated Liver tests
• Approach to patient with elevated Liver tests
– History, examination and lab features of chronic liver disease
liver disease
• Core conditions
– Fatty Liver
– Alcohol
– Viral Hepatitis
Thanks to:
Thanks to:
• Dr Saket Singhal, SWBH
• Alcohol Care Team
Alcohol Care Team
• GP Hot Topics
Resources
• This talk on intranet (video)
• British Liver Trust British Liver Trust
– patient & professionals leaflets / multi‐lingual
• Thealcohollearningcentre.org.uk
– Excellent e‐elearningg
• Nafldscore.com – Angulo score