Latest Version Final version February 2023

Previous December 2013, February 2016, February

Versions 2019 “Must do” actions for GP’s / (Triaged
Pi
by RSS)
Review Date February 2026
B Recommendations for Primary Care
Approving Body NCL ICB CAG R Red flag / urgent referral

Adult Abnormal Liver Function Tests Primary Care NCL-Wide /

Borough(s) NCL-Wide O Routine referral

Clinical Pathway Author(s) Dr Nick Dattani, Louis China, Douglas

P Public health intervention

Macdonald G Audio-visual aids for patients and GP

For any queries regarding the content of this document e-mail: nclicb.pathways@nhs.net Click icon for clinical evidence

1.0 (B) Right-click to use hyperlink

Patient has Abnormal LFTs:
Note: Alpha-numeric step references are
History and Examination with attention to Alcohol consumption, Metabolic
to aid printing in black & white and colour
Syndrome, BMI, blindness
Hepatotoxic Drugs &
test for HBsAg and HCV Ab
Investigations must be within 6
months of date of referral

2.0 (R) 3.0 (B) 4.0 (B) 5.0 (B)

Isolated Raised Normal Bilirubin with Normal Bilirubin with

Jaundice (Bil>40) and/or Bilirubin with other Hepatitic LFTs Cholestatic LFTs
significantly abnormal normal LFTs (ALT>ALP) (ALP>ALT)
LFTs and/or Liver aetiology
Concerns re↓albumin or suggested by ↑GGT
prolonged INR (if done) otherwise organise bone
7.0 (B) 9.0 (B) 10.0 (R)
Suspected malignancy aetiology and check
Most commonly due to Gilbert’s Vitamin D)
syndrome (unconjugated ALT<300 IU/L ALT>300 IU/L
hyperbilirubinaemia - affects
5% of the population and is
benign)
6.0 (R) 11.0 (Pi) 12.0 (R)
Less commonly due to
haemolysis Seek telephone
Urgent Ultrasound and/or
advice with on-call
Urgent 2 week referral or
medical team or
admission to appropriate Repeat within one month
8.0 (B) 8.1 (G) hepatology team
specialty with AST ,GGT, FBC to confirm
depending on
Repeat LFTs still elevated
availability
fasting sample Consider HCV and HBV
with split If alcohol consumption >14U/
bilirubin and Week advice and review NCL
13.0 (Pi)
FBC. Consider Alcohol Pathway [2]
reticulocytes Consider Ultrasound
and LDH if Advice and
haemolysis Guidance
suspected. If in doubt
If Gilbert’s
confirmed then
inform patient If abnormal
and provide
information [1]

14.0 (Pi)
Ultrasound & request Extended
Liver Test Panel which
includes:
• Hepatitis B & C
• Autoantibodies (ANA, USS Normal
AMA, smooth muscle Ab,
LKM*)
• Ferritin / Transferrin satn
• Caeruloplasmin USS abnormal
• Immunoglobulins
• A1 antitrypsin
• also HBA1c
Abnormal USS
Isolated raised LFTs but
appearances and/or
normal USS and Panel
Abnormal Liver Test Panel
15.0 (B) 16.0 (B) 17.0 (G)
If clinically appropriate seek
Manage in Primary Care: Fatty Liver Suggested by USS and Advise & Guidance
Lifestyle advice and repeat LFTs in 1 year Extended Liver Test Panel Negative for Refer to Liver Specialist for
other Pathology Page 2 (Fatty Liver) possible:
(if remains abnormal to Advice and • Viral Hepatitis
Guidance) • ALD with Advanced
Fibrosis
15.1 (G)
• PSC, PBC, Autoimmune
Hepatitis
• Gallstone disease
• Hepatic Vascular Disorders
• Hepatic Metabolic
Disorders
17.1 (O)

18.0 (R)
Consider urgent referral
pathway as clinically
appropriate

Consider doing LFTS

• if sx of liver/bile system disease e.g. abdo pain/nausea/vomiting/jaundice/fatigue/anorexia
• pt drinks excessively
• pt taking medication that affects the liver
• pt has diabetes or other metabolic disorder
• obesity
• GGT – useful in cholestasis or monitoring
• changes in alcohol consumption

Please note - LFTS are normal in up to 25% patients with cirrhosis. If If there are risk factors for liver disease (e.g. harmful alcohol, viral hepatitis) please test according to the relevant pathway.

[1] Gilberts’s Syndrome

http://www.nhs.uk/conditions/gilbertssyndrome/Pages/Introduction.aspx
[2] NCL Alcohol Pathway
[EDITING NOTE: To add in URL for NCL alcohol pathway once uploaded onto GP website]
*LKM=liver & kidney microsomal Ab
AMA = mitochondrial antibody
ANA = anti nuclear Ab