deranged lfts pathways
DESCRIPTION
Deranged LFTs Pathways. A H Mohsen. Dr A H Mohsen MD (KCL), MRCP, DTM&H Consultant Gastroenterologist. Main causes for progression of liver disease. Alcohol consumption Obesity Hepatitis B/C. Common serum liver chemistry tests. How common abnormal LFTs?. - PowerPoint PPT PresentationTRANSCRIPT
Deranged LFTsPathways
A H MohsenDr A H Mohsen
MD (KCL), MRCP, DTM&HConsultant Gastroenterologist
Main causes for progression of liver
disease
Alcohol consumption Obesity Hepatitis B/C
Common serum liver chemistry tests
AST/ALT Hepatocellular damage
Bilirubin Cholestasis, impaired conjugation, or biliary obstruction
GGT Cholestasis or biliary obstruction
Alk-P Cholestasis, infiltrative disease, or biliary obstruction
PT/Albumin Synthetic function
How common abnormal LFTs?
Abnormal LFTs: 1%–4% of the asymptomatic population
Those who have LFTs check: >10 are above twice limit of normal
abnormal test result resolve spontaneously in 38% of patients
Gastroenterology 2002
Ryder, BMJ 2001
149 asymptomatic patients with elevated alanine aminotransferase levels who
underwent liver biopsy
Cause %
Fatty live 56
Non-A, Non-B hepatitis 22
Alcohol related 11
Hepatitis B 3
Other diagnosis 8
No cause 2
Scand J Gastroenterol 1986
1124 consecutive patients with chronic elevations in aminotransferase levels
Cause Number
Steatosis 41
NASH 26
Fibrosis 4
Hepatitis B 3
Cirrhosis 2
Normal 8
Am J Gastroenterol 1999
81 no definable cause had LB
Abnormal LFTs
Raised ALK-PALT/ASTIsolated rise Bili up to 3x ULN
exclude haemolysis andConjugated bilirubin
Probably Gilbert’s
Abnormal LFTs
Raised ALK-PALT/ASTIsolated rise Bili up to 3x ULN
Check GGT
Raised: x2 ULN>3 months
Normal:Bone disease
USS & AMA
abnormal:refer
Normal: repeat in 3-6 monthsTrend not improving
ALT/AST
ALT>400100-400 mod RiskALT<100
Review 1 months
Raised: x2.5 ULN>3 months
Hep A,E,CMV,EBVUSS, liver screen
USS & liver screen Referral to Gast
Review 1-3 /12
No further action
Normal
USS & liver screen
Positive screenNegative screen
Treat diagnosis
Referral to Gast
Fat on USS
NAFLD + ETOH
No fat on USS
Fatty liver (NAFLD/NASH)
Fibro-scan
Referral to Gast
> 7
Criteria Low risk
High risk
Age <45 >45Diabetes/IFG
Absent Present
BMI <30 >30AST/ALT <1 >1Platelet count
>150 <150
Albumin >34 <34If > 3 criteria• Life style intervention• Repeat fibro-scan in 1-2 years• GP to monitor
< 7
Isolated elevation of GGT
Levels > 3 times upper limit of normal:Repeat in 3 monthsAlcohol intake adviceReview medicationsIf trends worsening
USS & fibro-scan
Levels < 3 times upper limit of normal:Monitor 6-12 monthlyAlcohol intake adviceReview medications
Refer to Gast
fibro-scan > 7
fibro-scan > 7
Recent case ST, 62 male Presented in March with severe UGIB
Stabilised OGD: Likely gastric varices (D/W
Addenbrokes) Catastrophic variceal bleed 10 hours later
Died PMH:
Type II DM (1999) Hypertension IHD
ST, 62 male Current medications:
1. NovoRapid 20-40 units pre meal2. Lantus 40 units pre bed3. Metformin MR 1g bd4. Bendroflumethiazide 2.5mg5. Omeprazole 5mg6. Diltiazem MR 90mg7. Irbesartan 75mg
Ref.Range
12/03/2014 22/09/2011 02/11/2010 27/10/2008 31/01/2007
ALP (30 - 130) 105 359 328 297 228
Albumin (35 - 50) 31 38 40 46 41
ALT (0 - 41) 37 74 88 93 78
Total Bilirubin
(0 - 20) 22 18 21 13 14
NAFLD prevalence Liver biopsy/post-mortem series
15-39% Third of the population was found to have
hepatic steatosis in US (MRI)
Obese persons NAFL 60-90%, NASH 20-25%, cirrhosis 2-
3% Diabetic : 50 % Morbidly obese and diabetic person
NAFL 100%, NASH 50%, cirrhosis 19%Dixon J 2001, silverman J 1989, 1990
Hultcrantz R 1986, Ground K 1982
Hepatology 2004; 40:1387
Examination ProcessA mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound.The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis. - the stiffer the liver is the greater the degree of fibrosis.
Project OverviewA novel diagnostic pathway to detect significant liver disease in the community
Amount Won £100,000
Innovation Challenge Prize Winner, November 2013
Summary
Clear pathways NAFLD is the most common cause 1/3 of deranged LFTs resolve
spontaneously Identify those at risk and refer
early