Guidelines on the management of abnormal liver blood tests

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Abstract

These updated guidelines on the management of abnormal liver blood tests have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines, which this document supersedes, were written in 2000 and have undergone extensive revision by members of the Guidelines Development Group (GDG). The GDG comprises representatives from patient/carer groups (British Liver Trust, Liver4life, PBC Foundation and PSC Support), elected members of the BSG liver section (including representatives from Scotland and Wales), British Association for the Study of the Liver (BASL), Specialist Advisory Committee in Clinical Biochemistry/Royal College of Pathology and Association for Clinical Biochemistry, British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN), Public Health England (implementation and screening), Royal College of General Practice, British Society of Gastrointestinal and Abdominal Radiologists (BSGAR) and Society of Acute Medicine. The quality of evidence and grading of recommendations was appraised using the AGREE II tool. These guidelines deal specifically with the management of abnormal liver blood tests in children and adults in both primary and secondary care under the following subheadings: (1) What constitutes an abnormal liver blood test? (2) What constitutes a standard liver blood test panel? (3) When should liver blood tests be checked? (4) Does the extent and duration of abnormal liver blood tests determine subsequent investigation? (5) Response to abnormal liver blood tests. They are not designed to deal with the management of the underlying liver disease.

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Most cited references 43

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AGREE II: advancing guideline development, reporting and evaluation in health care.

M. Brouwers, M E Kho, G P Browman … (2010)

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Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography.

Henry Lik-Yuen Chan, Angel Mei-Ling Chim, Jennifer Ong … (2012)

Knowledge of the epidemiology of non-alcoholic fatty liver disease (NAFLD) is incomplete because liver biopsy cannot be performed on the general population to assess disease severity. New non-invasive tests allow accurate and safe assessment in healthy individuals. The aim of this study was to examine the prevalence of NAFLD and advanced fibrosis in the general Hong Kong Chinese population. Subjects were recruited from the community by random selection from the government census database. Liver fat and fibrosis were assessed by proton-magnetic resonance spectroscopy and transient elastography, respectively. Overall, 264 of 922 (28.6%) subjects had intrahepatic triglyceride content ≥5%. Excluding 12 subjects with significant alcohol consumption, the population prevalence of NAFLD was 27.3% (95% CI 24.5% to 30.2%). Each component of the metabolic syndrome increased the risk of fatty liver in a dose-dependent manner (prevalence of 4.5% in subjects without any component and 80.0% in those with all five components). 8 (3.7%) patients with fatty liver had liver stiffness ≥9.6 kPa, a level suggestive of advanced fibrosis. Body mass index and alanine aminotransferase level were independent factors associated with liver stiffness. Together with other clinical prediction scores, the estimated prevalence of advanced fibrosis in patients with fatty liver in the community was <10%. Compared with non-drinkers, modest drinkers (<10 g per day) did not have higher risk of fatty liver after adjustment for demographic and metabolic factors. The liver stiffness was 4.7±1.9 kPa in modest drinkers and 4.6±1.7 kPa in non-drinkers (p=0.54). NAFLD is found in over a quarter of the general adult Chinese population, but the proportion of patients with advanced fibrosis is low. Modest alcohol consumption does not increase the risk of fatty liver or liver fibrosis.

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Liver stiffness in nonalcoholic fatty liver disease: A comparison of supersonic shear imaging, FibroScan, and ARFI with liver biopsy.

Christophe Cassinotto, Jerome Boursier, Victor de Lédinghen … (2016)

Nonalcoholic fatty liver disease (NAFLD) has become a major public health issue. The goal of this study was to assess the clinical use of liver stiffness measurement (LSM) evaluated by supersonic shear imaging (SSI), FibroScan, and acoustic radiation force impulse (ARFI) in a cohort of NAFLD patients who underwent liver biopsy. A total of 291 NAFLD patients were prospectively enrolled from November 2011 to February 2015 at 2 French university hospitals. LSM was assessed by SSI, FibroScan (M probe), and ARFI within two weeks prior to liver biopsy. Calculations of the area under the receiver operating curve (AUROC) were performed and compared for the staging of liver fibrosis. AUROC for SSI, FibroScan, and ARFI were 0.86, 0.82, and 0.77 for diagnoses of ≥F2; 0.89, 0.86, and 0.84 for ≥F3; and 0.88, 0.87, and 0.84 for F4, respectively. SSI had a higher accuracy than ARFI for diagnoses of significant fibrosis (≥F2) (P = 0.004). Clinical factors related to obesity such as body mass index ≥ 30 kg/m(2) , waist circumference ≥102 cm or increased parietal wall thickness were associated with LSM failures when using SSI or FibroScan and with unreliable results when using ARFI. In univariate analysis, FibroScan values were slightly correlated with NAFLD activity score and steatosis (R = 0.28 and 0.22, respectively), whereas SSI and ARFI were not; however, these components of NAFLD did not affect LSM results in multivariate analysis. The cutoff values for SSI and FibroScan for staging fibrosis with a sensitivity ≥90% were very close: 6.3/6.2 kPa for ≥F2, 8.3/8.2 kPa for ≥F3, and 10.5/9.5 kPa for F4.

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Author and article information

Journal

Journal ID (nlm-ta): Gut

Journal ID (iso-abbrev): Gut

Journal ID (hwp): gutjnl

Journal ID (publisher-id): gut

Title: Gut

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0017-5749

ISSN (Electronic): 1468-3288

Publication date (Print): January 2018

Publication date (Electronic): 9 November 2017

Volume: 67

Issue: 1

Pages: 6-19

Affiliations

[1 ] departmentNational Institute for Health Research (NIHR), Birmingham Biomedical Research Centre and Centre for Liver Research , University of Birmingham , Birmingham, UK

[2 ] departmentCentre for Liver Research , Institute of Immunology and Immunotherapy, University of Birmingham , Birmingham, UK

[3 ] Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust , Leeds, UK

[4 ] departmentDivision of Molecular and Clinical Medicine , School of Medicine, University of Dundee , Dundee, UK

[5 ] The Pool Medical Centre , Studley, UK

[6 ] departmentDepartment of Radiology , Cambridge University Hospitals NHS Foundation Trust , Cambridge, UK

[7 ] Liver4Life , Dorset, UK

[8 ] Public Health England , South West, UK

[9 ] departmentRegional Liver and Transplant Unit , Freeman Hospital , Newcastle Upon Tyne, UK

[10 ] departmentInstitute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne, UK

[11 ] British Liver Trust , Bournemouth, UK

[12 ] PBC Foundation , Edinburgh, UK

[13 ] Killick Street Health Centre , London, UK

[14 ] NHS Islington Clinical Commissioning Group , London, UK

[15 ] departmentClinical and Experimental Science, Faculty of Medicine , University of Southampton , Southampton, UK

[16 ] Chair of Trustees PSC Support , Didcot, UK

[17 ] departmentGwent Liver Unit , Royal Gwent Hospital , Newport, UK

Author notes

[Correspondence to ] Professor Philip N Newsome, NIHR Birmingham Biomedical Research Centre and Centre for Liver Research, Institute of Biomedical Research, University of Birmingham, Birmingham B15 2TT, UK; p.n.newsome@ 123456bham.ac.uk

Author information

Philip N Newsome http://orcid.org/0000-0001-6085-3652

Article

Publisher ID: gutjnl-2017-314924

DOI: 10.1136/gutjnl-2017-314924

PMC ID: 5754852

PubMed ID: 29122851

SO-VID: 2f360af5-a293-44ee-acef-d65916622ac1

License:

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

History

Date received : 26 July 2017

Date revision received : 06 October 2017

Date accepted : 15 October 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;

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access-type free

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: fibrosis,liver,nonalcoholic steatohepatitis,alcoholic liver disease

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ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: fibrosis, liver, nonalcoholic steatohepatitis, alcoholic liver disease

Guidelines on the management of abnormal liver blood tests

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Most cited references 43

AGREE II: advancing guideline development, reporting and evaluation in health care.

Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography.

Liver stiffness in nonalcoholic fatty liver disease: A comparison of supersonic shear imaging, FibroScan, and ARFI with liver biopsy.

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