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      Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community


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          To describe the development of the Nottingham liver disease stratification pathway, present a 12-month evaluation of uptake and stratification results, and compare the pathway with current British Society of Gastroenterology (BSG) guidelines.


          A referral pathway between primary and secondary care for the detection and risk stratification of liver disease.


          Four Nottinghamshire clinical commissioning groups (700 000 population).


          Patients are referred to the pathway with (1) raised aspartate aminotransferase to alanine aminotransferase (AST:ALT) ratio, (2) harmful alcohol use or (3) risk or presence of non-alcoholic fatty liver disease (NAFLD).


          We report on clinic attendance within secondary care for transient elastography (TE) and brief lifestyle intervention. The TE result is reported back to the general practitioner with advice on interpretation and referral guidance.

          Main outcome measures

          Pathway uptake, patient characteristics, liver disease stratification results and stakeholder feedback.


          Over the first 12 months 968 patients attended a TE clinic appointment, with raised AST:ALT ratio being the most common single reason for referral (36.9%). Of the total, 222 (22.9%) patients had an elevated liver stiffness (≥8 kPa), in whom 57 (25.7%) had a liver stiffness which was indicative of advanced chronic liver disease. If a traditional approach based on raised liver enzymes (BSG guidance) had been followed, 38.7% of those with significant liver disease (≥8 kPa) would have gone undetected among those referred for either NAFLD or raised AST:ALT ratio.


          Targeting patients with risk factors for chronic liver disease and stratifying them using TE can detect significant chronic liver disease above and beyond the approach based on liver enzyme elevation.

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          Most cited references9

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          Guidelines on the management of abnormal liver blood tests

          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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            Prevalence of clinically significant liver disease within the general population, as defined by non-invasive markers of liver fibrosis: a systematic review.

            As of 2016, there is no evidence-based pathway to stratify the risk of chronic liver disease in a general population setting. Non-invasive tests of liver fibrosis might provide a mechanism for earlier diagnosis. These tests have been extensively validated in the hospital setting but their performance in a general population setting is unclear. We did a systematic review of non-invasive tests used to stratify patients at risk of clinically significant liver disease in a general population setting and report the prevalence of chronic liver disease as defined by these tests. We systematically searched Embase, MEDLINE, Web of Science, reference lists from the original studies identified, and recent conference proceedings. All study designs were considered. 19 studies were identified, in which 11 non-invasive tests were used. Only transient elastography and FibroTest were compared with histological endpoints. The prevalence of liver fibrosis varied between 0·7% and 25·7%. More focused stratification for advanced liver fibrosis (0·9-2·0%) or cirrhosis (0·1-1·7%) narrowed the estimates of prevalence. Investigators from studies targeting patients with risk factors of liver disease, such as non-alcoholic fatty liver disease, hazardous alcohol use, or type 2 diabetes, reported higher prevalence of advanced liver fibrosis (0-27·9%) and cirrhosis (2·4-4·0%) than those in the general population. Validated non-invasive tests for liver fibrosis consistently detected otherwise unrecognised liver disease in the general population. Reliance on abnormal liver function tests will miss most patients with significant liver injury. New pathways to stratify chronic liver disease, with the use of non-invasive markers of liver fibrosis, are needed in the general population setting.
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              Direct targeting of risk factors significantly increases the detection of liver cirrhosis in primary care: a cross-sectional diagnostic study utilising transient elastography

              Objectives To assess the feasibility of a novel diagnostic algorithm targeting patients with risk factors for chronic liver disease in a community setting. Design Prospective cross-sectional study. Setting Two primary care practices (adult patient population 10 479) in Nottingham, UK. Participants Adult patients (aged 18 years or over) fulfilling one or more selected risk factors for developing chronic liver disease: (1) hazardous alcohol use, (2) type 2 diabetes or (3) persistently elevated alanine aminotransferase (ALT) liver function enzyme with negative serology. Interventions A serial biomarker algorithm, using a simple blood-based marker (aspartate aminotransferase:ALT ratio for hazardous alcohol users, BARD score for other risk groups) and subsequently liver stiffness measurement using transient elastography (TE). Main outcome measures Diagnosis of clinically significant liver disease (defined as liver stiffness ≥8 kPa); definitive diagnosis of liver cirrhosis. Results We identified 920 patients with the defined risk factors of whom 504 patients agreed to undergo investigation. A normal blood biomarker was found in 62 patients (12.3%) who required no further investigation. Subsequently, 378 patients agreed to undergo TE, of whom 98 (26.8% of valid scans) had elevated liver stiffness. Importantly, 71/98 (72.4%) patients with elevated liver stiffness had normal liver enzymes and would be missed by traditional investigation algorithms. We identified 11 new patients with definite cirrhosis, representing a 140% increase in the number of diagnosed cases in this population. Conclusions A non-invasive liver investigation algorithm based in a community setting is feasible to implement. Targeting risk factors using a non-invasive biomarker approach identified a substantial number of patients with previously undetected cirrhosis. Trial registration number The diagnostic algorithm utilised for this study can be found on clinicaltrials.gov (NCT02037867), and is part of a continuing longitudinal cohort study.

                Author and article information

                Frontline Gastroenterol
                Frontline Gastroenterol
                Frontline Gastroenterology
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                March 2020
                26 June 2019
                26 June 2019
                : 11
                : 2
                : 86-92
                [1 ] departmentNIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and the University of Nottingham , Nottingham, UK
                [2 ] Nottingham Digestive Diseases Centre , Nottingham, UK
                [3 ] Northern Lincolnshire and Goole Hospitals NHS Foundation Trust , Grimsby, Lincolnshire, UK
                [4 ] Greater Nottingham Clinical Commissioning Group , Nottingham, UK
                [5 ] departmentDivision of Epidemiology and Public Health , University of Nottingham , Nottingham, UK
                Author notes
                [Correspondence to ] Dr Indra Neil Guha, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK; neil.guha@ 123456nottingham.ac.uk

                JC and EW are joint first authors.

                JM and ING are joint senior authors.

                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/.

                Funded by: FundRef http://dx.doi.org/10.13039/501100002001, Health Services and Delivery Research Programme;
                Award ID: BRC-1215-20003
                Original research
                Custom metadata

                Gastroenterology & Hepatology
                liver function test,fatty liver,alcoholic liver disease
                Gastroenterology & Hepatology
                liver function test, fatty liver, alcoholic liver disease


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