Advice and Guidance or refer to outpatients both available via eRS Urgent Referral Urgent ultrasound andor Consider USC 2WW or urgent referral or admission see Red flags in Remedy ID: 1045139
Download Presentation The PPT/PDF document "Consider specialist input – request" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Consider specialist input – request Advice and Guidance or refer to outpatients (both available via eRS)Urgent ReferralUrgent ultrasound and/orConsider USC (2WW) or urgent referral or admission (see Red flags in Remedy)ALP/GGTabnormal after 3 monthsSynthetic failure Jaundice, low albumin prolonged INRORSuspected malignancyWeight loss +Abnormal liver enzymesMainly cholestatic liver enzymes:Raised ALP and GGT**Suspected alcohol misuse? Follow alcohol pathway simultaneously - RemedyHistoryAlcohol history / Metabolic syndrome/medication.Risk factors for viral hepatitis/family history/ comorbidities(If self-limiting acute explanatory cause identified (such as drug, inter-current illness, comorbidity, H/O travel, insect bites, muscle injury etc) repeat blood tests recommended before proceeding to USS) Abnormal USS appearances and/or positive NILSNormal USS/ negative NILS /no alcohol misusePerform NILS and then Ultrasound if no self- limiting acute explanatory cause **Abnormal liver blood tests (LBT) algorithmNon-invasive liver screen (NILS) – see ICE profileHBsAg / HCV Ab, HIVAutoimmune profile, Immunoglobulins, Coeliac serology, Alpha 1 AntitrypsinFerritin (+ transferrin saturation if raised)HbA1c, Lipid profileCopper/Caeruloplasmin (if age <40)Consider FIB-4 (if metabolic syndrome risk factors)If Gilbert’s Syndromeconfirmed,then inform patient and provide information Isolated raised bilirubin with otherwise normal liver blood tests Repeat LBTs with conjugated bilirubin and FBCConsider haemolysis:check reticulocytes/LDH/haptoglobinMost commonly due to Gilbert’s syndrome (unconjugated hyperbilirubinaemia)Mainly hepatitic liver enzymes:Raised ALT/ASTNILSif no self-limiting acute explanatory cause identified then also request UltrasoundALT/AST stillabnormal after 3 monthNormal USS/ negative NILS/ no MASLD risk factors / no alcohol misuseFollow MASLD pathway-see Remedy Metabolic syndrome risk factorspresentAbnormal USS appearances and/or positive NILS*Updated January 2024*Anti-smooth muscle antibody has a significant false positive rate - an isolated ASMA with normal ALT and IgG is unlikely to represent autoimmune hepatitis(**if isolated ALP rise and GGT normal, then consider drugs/bone disease. Isolated GGT rarely requires investigation)