New guidelines aim to prevent medics from failing to diagnose patients with liver disease

New recommendations, led by experts at the University of Birmingham, have been published to improve the use of liver blood tests.

The recommendations, published in Gut, are aimed at helping healthcare workers diagnose patients with liver disease as well as preventing unnecessary repeat tests for people unlikely to have significant liver disease.

While the number of deaths from other common conditions is falling in the UK, those due to liver disease have been increasing dramatically, with a 400% increase in death rates between 1970 and 2010. Death rates due to liver disease has also risen sharply in younger people, with a 500% increase in the same period for those aged under 65.

Lead author Professor Philip Newsome, Director of the Centre for Liver Research at the University of Birmingham’s Institute of Immunology and Immunotherapy, said: “Liver disease develops silently; there may be no signs or symptoms until the complications of liver failure develop.

“Since the current liver blood tests were developed in the 1950s, they have been the mainstay of liver disease identification. Unfortunately the way liver blood tests are interpreted means that many patients with liver disease are not identified until at a late stage.

“Liver blood or function tests are checked ever more frequently in both primary and secondary care in an attempt to exclude liver disease, for the monitoring of potential adverse effects of drugs on the liver such as statins, and for the investigation of the generally unwell patient.

“These tests often produce an abnormal result, the clinical significance of which is unclear.

“In many cases they are requested in response to non-specific symptoms where there is little potential link between symptoms and likelihood of liver disease, or the blood tests are performed for unrelated reasons such as chronic disease monitoring.

“This frequently leads to a cycle of additional liver blood test testing in an otherwise asymptomatic individual. Notably, many patients referred to hospital with abnormal liver tests do not have any evidence of significant liver disease.”

The new guidelines, which cover both adults and children, recommend that initial investigation in patients with potential liver disease should include bilirubin, albumin, ALT, alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) plus a complete blood count.

They also include definitions for ‘abnormal’ blood tests and advise when patients should have liver blood tests, as well as offering advice on pathways and tools for managing patients with abnormal test results.

Professor Newsome adds: “The pathways will be freely disseminated and should be incorporated into primary care IT systems to allow automatic calculation of risk scores when appropriate, to ensure recommendations can be put into practice.”

They also state that research is needed to establish the most cost-effective approach to identify patients with alcohol-related liver disease and non-alcoholic fatty liver disease at risk of having advanced liver fibrosis.

The recommendations now supersede earlier guidelines in 2000 and were commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology.

For further information or interviews contact Emma McKinney, Press Office, University of Birmingham, at +44 (0)121 414 6681 or contact the Press Office out of hours on +44 (0)7789 921165.

• The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 5,000 international students from over 150 countries.
• Newsome et al (2017). ‘Guidelines on the management of abnormal liver blood tests’. Gut. http://dx.doi.org/10.1136/gutjnl-2017-314924
• To read the recommendations click here
• For morbidity, in England and Wales, 57 682 hospital admissions and 10 948 deaths were due to liver disease in 2012.
• In England and Wales, 57,682 hospital admissions and 10,948 deaths were due to liver disease in 2012.
• Authors of the guidelines were Philip N Newsome, Rob Cramb, Suzanne M Davison, John F Dillon, Mark Foulerton, Edmund M Godfrey, Richard Hall, Ulrike Harrower, Mark Hudson, Andrew Langford, Anne Mackie, Robert Mitchell-Thain, Karen Sennett, Nicholas C Sheron, Julia Verne, Martine Walmsley and Andrew Yeoman.
• The authors are affiliated to the following organisations:

1. National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
2. Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
3. Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
4. Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
5. The Pool Medical Centre, Studley, UK
6. Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
7. Liver4Life, Dorset, UK
8. Public Health England, South West, UK
9. Regional Liver and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
10. Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
11. British Liver Trust, Bournemouth, UK
12. PBC Foundation, Edinburgh, UK
13. Killick Street Health Centre, London, UK
14. NHS Islington Clinical Commissioning Group, London, UK
15. Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, UK
16. Chair of Trustees PSC Support, Didcot, UK
17. Gwent Liver Unit, Royal Gwent Hospital, Newport, UK