HNY Policy and Pathway Repository - York

NAFLD (Non-Alcholic Fatty Lever Disease) – Hepatic manifestation of the metabolic sybdrome. Most common cause of abnormal LFT’s in developed countries and is thought to effect 40-70% of patients with Type II diabetes. Risk factors include insulin resistance (impaired fasting glucose or diabetes), age, obesity, smoking and persistently raised ALT.

• Jaundice
• Signs of hepatic decompensation (acites, coagulopathy, flap/encephalopathy, low albumin)
• Admission or urgent referral indicated if the above present

Asymptomatic LFT abnormalities

Causes

• Alcohol excess – LFT’s should be considered in all patients with hazardous drinking behavior
• Obesity and progression to NAFLD
• Chronic hepatitis B and C infection
• Medication – statins are a common cause of abnormal LFT’s however they don’t cause liver injury

Initial management

• Mildly elevated LFT’s do not require secondary care referral but if >3x normal limit then referral or advice from gastroenterology should be considered.
• Manage lifestyle factors – BMI, alcohol, medication (including herbal remedies), discuss risk factors for hepatitis.
• Repeat in 3-6 months

After 3-6 months:

• Raised isolated Bilirubin
  • Gilberts syndrome if Hb normal – Reassure and give PILS leaflet
  • Haemolysis if Hb low and consider Haematology referral
• Raised ALP
  • Confirm hepatic origin by confirming raised gamma GT 
  • Perform USS and autoimmune/immunoglobulin screen
    • If abnormal – refer
    • If normal repeat LFT’s at 6 weeks and refer if ALP>1.5x upper limit otherwise watch and wait.
• Raised transaminases +/- ALP
  • Perform USS and Liver screen
    • FBC, U&E, glucose, lipids, bone profile, ferritin, coagulation, coeliac screen, hepatits serology, Autoimmune/immunology screen, alpha 1 antitrypsin, caeruloplasmin (excludes Wilson’s disease).
  • If alcohol excess and liver screen negative consider referral to alcohol team
  • Suspected NAFLD – refer if diabetic and BMI>28 and/or AST:ALT ratio>0.8. Otherwise review annually and promote healthy lifestyle
  • Hepatitis B positive – refer
  • Hepatitis C positive
    • Perform Hep C viral load
      • If positive – refer
      • If negative – repeat at 3 months and if still negative reassure that infection has cleared, no need to refer
  • Ferritin >500 perform iron studies and if iron saturation>65% then refer, if not consider alternative cause
  • Refer if coeliac positive, alpha 1 antitrypsin low, anti-smooth muscle antibody or anti-mitrochondrial antibody positive, raised IgG or IgM or if there is no obvious cause.
  • Also refer if there is pre-existing liver disease and the clinical picture has changed

Information to include in referral letter

• Alcohol and presence of obesity with results of investigations to-date.
• Relevant past medical / surgical history
• Current regular medication
• BMI/ Smoking status
   

Investigations prior to referral

As above

Patient Information Leaflets/ PDAs

http://www.patient.co.uk/health/gilberts-syndrome

http://www.patient.co.uk/health/liver-function-tests

http://www.patient.co.uk/health/hepatitis-b
 

References

1. https://rms.Kernow.nhs.uk 
2. Godlee (2011). NAFLD. BMJ 343, 4652
3. Ainste et al (2011). How big a problem is NAFLD. BMJ 343, 3897
4. Bhala et al (2013).How to tackle rising death rates of liver disease. BMJ 346, f807.