Asymptomatic abnormal LFTs…..again!

1. Asymptomatic abnormal LFTs…..again! ignore, reassure, investigate or refer? Alastair MacGilchrist Laboratory/Primary care Meeting 7 November 2013

2. Why bother? (1)

3. Why bother? (2) • Liver disease is usually asymptomatic until irreversible…..the classic “silent killer” • Most liver disease is due to alcohol, NAFLD or viral hepatitis…..all preventable or reversible in early stages

5. Alcohol kills a Scot every 3 hours • 1 in 20 of all deaths in Scotland • Twice that of England • Doubled in last 15 years • 1 in 10 of deaths in Scots aged 35-54 is due to alcoholic liver disease. • Enough alcohol is sold in Scotland to enable every adult to exceed safe drinking guidelines • almost double that of England • Britain’s consumption has doubled since 1960 • Alcohol is 70% more affordable than in 1980 Price  Consumption  Harm

7. NAFLD is a big problem • Very common • Up to 30% of population • Up to 75% if obese • 2-5% will develop cirrhosis over 20 years • Difficulty distinguishing progressive disease (i.e. fibrosis)

8. The future of hepatitis C therapy e.g. sofosbuvir, daclatasvir, ledipasvir interferon-free oral once-daily dosing single combi-pill short course minimal side effects

9. hepatitis C therapy is changing

10. What are abnormal liver function tests? • bilirubin • ALT • alkaline phosphatase • GGT • albumin • AST • prothrombin time • FBC • creatinine

11. GGT v AST • GGT • isolated GGT with raised MCV – consider alcohol • in female NAFLD, GGT predicts cirrhosis • GGT indicates liver source for ALP • ignore GGT alone <100 • AST • in ALD, AST often > 2 x ALT • in NAFLD, suspect significant fibrosis if • AST > ALT (AST/ALT > 0.8) • APRI score (AST: platelet ratio) >1.5 routine LFTs in primary care: remove GGT and add AST?

12. The patient with asymptomatic abnormal LFTs • NAFLD is not the only diagnosis • Pattern and duration are important • Consider: • Alcohol history • Hepatitis risk factors • Drugs • metabolic syndrome clues • Autoimmune disease clues • Family history • Measure: • Viral hepatitis serology HBsAg, anti-HCV Ab HBV, HCV • Autoimmune markers ASMA, ANA, AMA AIH, PBC • Glucose NAFLD • Lipids NAFLD • Ferritin haemochromatosis • Caeruloplasmin (if <55y) Wilson’s disease • Alpha-1-antitrypsin phenotype α-1-Antitrypsin deficiency • Ultrasound

13. Have they got fibrosis/cirrhosis?1. Primary care • Clinical exam • Hepatosplenomegaly • Spider naevi, etc. • LFTs • GGT • AST/ALT • Albumin • Platelets • Ultrasound

14. Have they got fibrosis/cirrhosis?2. Secondary care • APRI score • Hyaluronic acid • Marker panels • ELF • Fibrotest • Elastography • Fibroscan • ARFI • Liver biopsy

15. “liver screen” • Who? ↑ALT/GGT/AP > 2 x ULN 2 occasions > 4 weeks apart • What? USS Aetiology HCV Ab, HBsAg ASMA, ANA, AMA ferritin caeruloplasmin (<55y) glucose, lipids (TTG, TFTs) Staging AST platelets albumin • Action? Refer if +ve aetiology screen fibrosis/cirrhosis ↓platelets AST/ALT>0.8 splenomegaly unexplained ALD ↓alcohol NAFLD ↓weight

16. Sub-groups • ↑bilirubin alone: usually Gilbert’s (exclude haemolysis) (check unconjugated) • ↑GGT alone: think alcohol (think NAFLD) • AP alone: probably not liver consider isoenzymes • ↑AP + GGT: usually biliary USS for biliary obstruction Check AMA for PBC

17. So…for the next patient with asymptomatic abnormal LFTs…. investigate? if persistent according to clinical picture don’t miss treatable disease refer? if require treatment, suspect advanced disease or diagnosis unclear reassure? if negative screen and no suspicion of advanced disease ignore? never!

18. and….. Your Text Here …..a very big thanks to Simon, Sara, Emily and Thulani