As the FY1, you will see patients with liver dysfunction either on the take or deranged LFTs when you are reviewing bloods. A focused approach can save you time & help you find the likely underlying cause to start investigating. It can also help you identify red flags that prompt urgent escalation.
Red flags (urgent escalation)
- Haemodynamic instability or worried about a patient
- Decompensated disease (newly jaundiced, encephalopathic, ascites)
- Synthetic dysfunction – i.e. deranged clotting, bruising/petechiae/purpura/bleeding
- Septic
- Suspicion of paracetamol OD
- Significant abdominal tenderness
History
- Duration
- Previous episodes
- Urine/stool colour
- Painful/painless
- Itching
- Systemic features: weight loss/fever/anaemia/arthralgia/myalgia/rash/fatigue
- Decompsenation features: abdominal swelling, fogginess, change in skin colour
- Alcohol intake: CAGE
- Travel (viral hepatitis/parasitic)
- Risk factors: IVDU/tattoos/piercings/blood transfusion/MSM/sex workers
- PMH: biliary surgery/gallstones/hepatitis/thyroid disease/NAFLD
- Drugs:
- Paracetamol & paracetamol containing medication
- Antibiotics: co-amox/fluclox/tuberculosis treatment
- statins
- NSAIDs
- anticonvulsants
- methotrexate
- herbal & OTC remedies
- oestrogens (contraceptive pill)
- Family Hx: anaemia/haemoglobinopathies/liver disease
- Possibility pregnancy (obstetric emergency) – usually occurs late in pregnancy so should be obviously pregnant
Examination
- Sepsis Sx: tachycardia/hypotension/fever
- CLD Sx: palmar erythema/spider naevi/gynaecomastia
- Visible abdominal collaterals
- Lymphadenopathy
- Hepato/splenomegaly with any palpable masses
- Decompensation: jaundice, ascites & encephalopathy (altered neuromuscular function with ataxia/nystagmus/asterixis or altered mental status)
- Murphy’s sign
Investigations
- Observations
- Urine dip
- FBC (haemolysis/infection/low platelets suggestive of portal hypertension with splenomegaly), U&E (renal impairment), LFTs: cholestatic (GGT; ALP), hepatitic (AST; ALT), split or unconjugated/conjugated bilirubin
- Synthetic function: Coagulation screen & albumin
- Viral hepatitis screen
- Hepatitis B surface Ag, surface Ab, core Ab
- Hepatitis C IgG (and if positive viral load/quantitative testing)
- Hepatitis A & E tend not to be chronic, consider testing if risk factors (travel/faecal-oral)
- US abdomen (CBD size, liver disease, gallstones, portal vein thrombosis – may need to ask for dopplers specifically)
- Blood cultures if any features to suggest infection
Advanced investigations (discuss with seniors)
- Paracetamol levels (unhelpful in staggered overdose, it is safer to treat than not treat if even mildly suspected but discuss with seniors)
- Immunoglobulins & Autoantibodies (on the advice of seniors)
- Ferritin (ferritin is frequently raised in the absence of haemochromatosis, may not be helpful)
- Alpha 1 antitrypsin (only in the context of respiratory disease or if suspicion for other reasons)
- Alpha-fetoprotein (it is usually cirrhotics who get HCC, so rarely any point doing if they’re not known cirrhotic)
- Caeruloplasmin (really rare!)
- TFTs (have a low threshold to do TFTs)
- EBV/CMV serology
- MRCP/ECRP & CT imaging (very much guided by seniors!)
Management
This depends on the underlying cause as one would expect however it is a good idea to discuss each case with your seniors
Are they cirrhotic?
- Do they have features to suggest splenomegaly or chronic liver disease?
- Do they need surveillance for varices?
- Do they have features of decompensation
- Ascites – US abdomen (to confirm unless obvious) & discuss with seniors with a view to referring to a gastroenterologist for consideration of tap for SBP, malignancy etc. & diuretics for excess fluid
- Encephalopathy – aim for 3 soft stools per day with as much lactulose & phosphate enemas as is required & discuss with seniors with a view to referring to a gastroenterologist
- Deranged clotting – unless contraindications, they require high dose vitamin K/phytomenadione (e.g. 10mg IV once daily for 3 days) based on local guidelines and if no contraindications. Note this doesn’t correct the deranged clotting if it is due to the liver, it simply treats an underlying vitamin K deficiency to unmask if it is truly due to liver dysfunction
Pre-hepatic (unconjugated hyperbilirubinaemia)Â
- Consider haemolysis or a haemoglobinopathy (are they anaemic? blood film? splenomegaly?)
- Infective causes of haemolysis usually will be obvious as the patient is quite unwell & will need discussion with seniors & management of sepsis
Hepatocellular
- Viral hepatitis, NAFLD & alcohol are by far the most common
- Viral hepatitis – diagnose and refer to gastroenterology
- NAFLD – aim for 10% weight reduction. discuss with gastroenterology about follow up and liver elastography
- Alcohol – refer to the substance misuse team
- About 3% of the population have Gilbert’s disease where intracellular conjugation is impaired which therefore causes an isolated unconjugated hyperbilirubinaemia. This is hereditary and usually requires no treatment
- Drug-induced liver disease is also quite common in hospital – carefully look at each drug in the BNF or contact the ward pharmacist. Be vigilant for paracetamol overdose & stop any offending drugs if it is safe to do so
- Cirrhosis from any cause
- If one of the rarer or inherited
Post hepatic
- If you suspect a post hepatic cause then escalation is always appropriate
- If painful or infective looking, always consider cholangitis. Manage this as you would any septic patient but with urgent escalation for consideration of MRCP/ERCP
- If painless, always consider pancreatic cancer or another malignant process
- Always think about portal vein thrombosis (again urgently escalate)
Further reading
- https://cks.nice.org.uk/jaundice-in-adults
- Raine, T., Dawson, J., Sanders, S., Eccles, S. (2014). Jaundice, Ch 9: Gastroenterology. In: Oxford Handbook for the Foundation Programme 4th Ed (pg. 318-319). Oxford: OUP.
- https://patient.info/doctor/jaundice-pro
By Dr Ashleigh Draper
Edits & additions by Dr Akash Doshi CT2
