Urgent Referral Urgent ultrasound andor Consider urgent referral to secondary care OP or admission ALPGGT abnormal after 3 months Synthetic failure Jaundice low albumin prolonged INR ID: 1045138
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1. Refer for Specialist inputUrgent ReferralUrgent ultrasound and/orConsider urgent referral to secondary care OP or admission ALP/GGTabnormal after 3 monthsSynthetic failure Jaundice, low albumin prolonged INRORSuspected malignancyWeight loss +Abnormal liver enzymesMainly cholestatic liver enzymes:Raised ALP/GGTSuspected alcohol misuse? Follow alcohol pathway simultaneouslyHistoryAlcohol history / Metabolic syndrome ?/medication reviewRisk factors for viral hepatitis?/family history/ comorbidities Abnormal USS appearances and/or positive NILSNormal USS/ negative NILS /no alcohol misuseLiver enzymes (if isolated ALP rise, confirm ALP of liver origin by checking GGT. If GGT normal, ALP could be due to drugs/bone disease)+Ultrasound+NILS Abnormal liver blood tests algorithmNon-invasive liver screen (NILS)HBsAg / HCV Ab, Hepatitis E serology, HIVAutoimmune profile, Immunoglobulins, Coeliac serology, Alpha 1 AntitrypsinFerritin (+ iron studies if raised)HbA1c, Lipid profileCopper/Caeruloplasmin (if age <40)Gilbert’s syndromeConfirmed,then inform patient and provide information Isolated raised bilirubin with otherwise normal liver blood tests Repeat LFT’s with conjugated bilirubin and FBCConsider haemolysis:check reticulocytes/LDH/haptoglobinMost commonly due to Gilbert’s syndrome (unconjugated hyperbilirubinaemia)Mainly hepatitic liver enzymes:Raised ALT/ASTUltrasound+NILS ALT/ASTabnormal after 3 monthsNormal USS/ negative NILS/ no NAFLD risk factors / no alcohol misuseFollow NAFLD pathway NAFLD?Metabolic syndrome risk factorspresent ?Abnormal USS appearances and/or positive NILSApril 2020