A 54 year old patient consults with a six-month history of lethargy, but no other significant red flag symptoms, and basic examination is unremarkable. At his next visit, the only "significant" finding of a tiredness screen is a raised ALT of 84u/L and his remaining LFTs are normal.
How significant is this finding? Should you be concerned, and how should you proceed?
On review of his notes, he had LFTs checked two years ago which showed an ALT of 65u/L but this was not acted on. At this time his BMI was 32. His medical problems are noted to be pre-diabetes, osteoarthritis, hypercholesterolaemia, obesity, atrial fibrillation and treated hypertension. His medications consist of bisoprolol, simvastatin and lisinopril and PRN naproxen. His CHAD2S2 VASc score is 1 and he has previously declined anticoagulation.
Key areas to focus on during your assessment
In cases of borderline or abnormal liver function tests ensure that you have taken a good history focusing on risk factors for liver disease, including questions such as:
- Is there a history of blood transfusions?
- Is there a history of intravenous drug use, or tattoos?
- Is there a history suggestive of alcohol dependence (consumption of more than 20g of ethanol a day, equivalent to 2.5 UK units, for women and 30g/day, equivalent to 3.75 units, for men)?
- Is there any family history of liver disease?
Physical examination of the patient should include body mass index (BMI), blood pressure (if no recent reading) and a brief check for stigmata of chronic liver disease, such as palmar erythema, hepatic flap, spider naevi, jaundice, or hepatomegaly. Be guided by the patient’s history.
If alcohol misuse is suspected, consider using an appropriate screening tool such as CAGE or AUDIT to further evaluate alcohol intake.
Findings of further assessment
In this case, the gentleman’s history reveals no significant risk factors and he drinks around 4-6 units a week of alcohol with no evidence of dependence. Examination reveals that he has a BMI of 38, his BP is 157/95 and there are no stigmata of chronic liver disease.
At this point you are likely to suspect non alcoholic fatty liver disease based on the features of metabolic syndrome in this patient.
After discussion, the patient undergoes a full liver screen including abdominal ultrasound and returns for review. His AST is 65u/L with no other blood abnormalities detected. Markers of synthetic liver function - platelet count, clotting and albumin - are normal.
Abdominal ultrasound scan reveals features consistent of fatty liver disease, with no other significant abnormalities.
A common scenario
This sort of scenario is common for GPs and has potentially significant implications for both patients and the NHS. There is good evidence that we need to be doing more with these abnormalities in primary care to identify those at risk of complications from fatty liver disease (whether alcoholic or non-alcoholic). The full scale of the problem however is still not fully known and could prove extremely difficult for GPs to assess, manage and review without additional resources in primary or secondary care.
What is fatty liver disease?
Fatty liver disease is a reversible condition thought to represent the hepatic manifestation of excess alcohol intake, metabolic syndrome or various other conditions, and its prevalence is rapidly increasing in adults and children. It is now regarded as a significant diagnosis in itself and its prevalence in Europe is thought to be 20-30%1.
Fatty liver disease can be classified into alcoholic or non-alcoholic fatty liver disease (NAFLD) due to a wide range of possible causes, and it can be histologically difficult to distinguish the two: the structural features within the cells, which show an abnormal accumulation of triglycerides in the liver cells due to a disruption of the fat metabolism, are pretty much the same in both forms. This fat-accumulation can lead to hepatocyte damage and rises in enzyme levels (ALT and AST). It can also, in 10-30% of patients eventually result in progressive fat-induced inflammation (steatohepatitis)2, which, again, based on the established underlying cause, can be classed as alcoholic steatohepatitis (ASH, part of alcoholic liver disease) and non-alcoholic steatohepatitis (NASH).
Ultimately, complications such as irreversible liver fibrosis/cirrhosis and subsequent hepatocellular carcinoma or liver failure may follow. Interestingly, the extent of inflammatory response can differ between individuals and does not necessarily correlate with the degree of fat accumulation.
Fatty liver disease is typically asymptomatic and found incidentally on routine biochemical screening – about 50% of patients with simple steatosis have elevated LFTs. Because of the potential of subsequent deterioration and complications it is important to pick up and follow up abnormal findings and to act on them.
NAFLD is present in over 50% of adults with type 2 diabetes or metabolic syndrome. This can progress to fibrosis, cirrhosis and hepatocellular cancer. It is becoming increasingly recognised in children.1
Important! NAFLD is present in over 50% of adults with type 2 diabetes or metabolic syndrome.
NAFLD management in primary care
The management of mild NAFLD can be appropriate in primary care. It is good practice to risk stratify the patient using the NAFLD fibrosis calculator at www.nafldscore.com.3 This requires age, BMI, LFTs and platelets, along with a recent HbA1c (see box).
|Interpretation of NAFLD score|
Less than -1.455 excludes fibrosis (negative predictive value of 93%)
Management focuses on:
- Gradual weight loss
- Increased exercise levels
- Stopping smoking
- Reducing alcohol (even in NAFLD)
- Cholesterol management if elevated
- Good BP control if relevant
- Good diabetic control if relevant
Think about how you follow up those patients who are not on other QOF registers thus not getting annual reviews. Code their condition and ask the patient to ensure they have their LFTs checked every year. Ensure they are aware of the significance of NAFLD. Use patient literature, leaflets or online resources to support this.
There is no clear guidance on how often these patients require ultrasound scans to ensure there is no progression of the NAFLD. Some GPs already have direct access to fibroscans. The enhanced liver fibrosis (ELF) test detects advanced liver fibrosis in those with already diagnosed NAFLD.1
Consider referral to a hepatologist if the patient’s NAFLD fibrosis score is more than -1.455. In this setting, a fibroscan may be carried out to look at the stiffness of the liver. It is ultrasound-based and non-invasive and provides an alternative to liver biopsy, which can be very painful and lead to complications such as capsular bleeding.
- Dr Pipin Singh is a GP in Northumberland
- NICE Non-alcoholic fatty liver disease (NAFLD): assessment and management. NICE: London. July 2016
- Revised Newcastle, North Tyneside and Northumberland guidelines for the management of adults with asymptomatic liver function abnormalities. August 2014. http://www.northoftyneapc.nhs.uk/wp-content/uploads/sites/6/2014/09/Guidelines-for-the-Management-of-Adults-with-Asymptomatic-Liver-Function-Abnormalities-August-2014.pdf