Wd.nottinghamcitycare.nhs.uk



Nottinghamshire Adult Liver Disease Stratification pathway

Information required to request a Fibroscan

Hazardous alcohol

This encompasses both those with alcohol dependence / alcoholism as well as those whose drinking is excessive (M> 50 U/week or F>35 U/week for several months).

Read codes:

|Hazardous Alcohol Use |XaKVA  |

|Harmful Alcohol Use                       |XaKVB   |

|Problem Drinker                               |Ub01R   |

|Higher Risk Drinking             |XaXje   |

|Chronic Alcoholism                          |XE1YQ  |

|Alcohol Abuse                                   |Xa1y2 |

|Alcohol intake above recommended sensible limits  |136K  |

|Alcohol Dependence Syndrome NOS                 |E232       |

For those with alcohol dependence / alcoholism they need to be willing to consider reducing their drinking before deciding whether to scan.

For those with excessive drinking there is good evidence that brief intervention is helpful in changing behaviours, which can be included in the consultation when discussing the scan

Diabetes/Metabolic syndrome/Fatty liver on USS

1) If there is type 2 diabetes and abnormal LFTs use the abnormal LFT part of this pathway.

2) Required to calculate the Fatty Liver Index (FLI):

• BMI

• waist circumference

• Gamma GT

• Triglyceride levels

Calculators are available on EMIS and TPP and a calculator can also be found on ICE.

Or Google: “Fatty Liver Index Calculator”

Abnormal LFTs

Fibroscan only indicated to stratify liver failure risk for raised ALT side of algorithm. It is not a diagnostic tool, hence screening for underlying cause of liver disease is essential:

• Hepatitis B & C

• Ferritin

• ANA

• Liver autoantibodies

• Immunoglobulins

-----------------------

High bilirubin (up to 50) + normal liver enzymes & normal FBC

Type 2 diabetes or

metabolic syndrome *

syndrome *

BMI > 35

Calculate Fatty Liver Index (FLI*) via ICE

Incidental fatty

liver on USS

Hazardous alcohol *

Asymptomatic Abnormal LFTs

Consider gallstones

BUT Jaundice or

possible cancer

Symptomatic + Abnormal

Liver Enzymes

Nottinghamshire Adult Liver

Disease Stratification pathway

Two week wait

Hepatobilary referral

FLI < 60

Consider checking conjugated /unconjugated bilirubin to confirm Gilbert’s Disease –benign condition

Willing to consider lifestyle behaviours

FLI > 60

Re check FLI every 5 years

NAFLD

Raised ALT

Raised Alk Phos only(>160)*

GGT then done automatically

Hepatitis B & C*

ANA

Liver autoantibodies

Immunoglobulins

Ferritin *

Refer +ves

to Hepatology

Raised Alk Phos with normal GGT

Raised Alk Phos with raised GGT

Refer for Fibroscan

ALT >100*

but

AST/ALT

Ratio ................
................

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