Guidelines on the management of abnormal liver blood tests
British Society of Gastroenterology (BSG) · 2017 · United Kingdom
Source and licence
- Authors
- Philip N Newsome, Rob Cramb, Suzanne M Davison et al.
- Title
- Guidelines on the management of abnormal liver blood tests
- Journal
- Gut, 2017
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC5754852
Licence statement of the original publication
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Recommendations list
- Recommendation 1Initial investigation for potential liver disease should include bilirubin, albumin, alanine aminotransferase (ALT), alkaline phosphatase (ALP) and γ-glutamyltransferase (GGT), together with a full blood count if not already performed within the previous 12 months.level 2b, grade B
- Research Recommendation 1: Further evidence is required to establish the cost-effectiveness of case finding for non-alcoholic fatty liver disease (NAFLD) in high-risk groups before it can be recommended.level 5, grade D
- Recommendation 2Abnormal liver blood test results should only be interpreted after review of the previous results, past medical history and current medical condition.level 5, grade D
- Recommendation 3The extent of liver blood test abnormality is not necessarily a guide to clinical significance. This is determined by the specific analyte which is abnormal (outside the reference range) and the clinical context.level 5, grade D
- Recommendation 4Patients with abnormal liver blood tests should be considered for investigation with a liver aetiology screen irrespective of level and duration of abnormality. Abnormal refers to an analyte which is outside the laboratory reference rangelevel 2b, grade B
- Recommendation 5In adults a standard liver aetiology screen should include abdominal ultrasound scan (USS), hepatitis B surface antigen, hepatitis C antibody (with follow-on polymerase chain reaction (PCR) if positive), anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin and transferrin saturation.level 2b, grade C
- Recommendation 6In children, ferritin and transferrin saturation may not be indicated, but autoantibody panel should include anti-liver kidney microsomal antibody and coeliac antibodies. Alpha-1-antitrypsin level and caeruloplasmin (age >3 years) should be included, and abnormalities discussed with an appropriate inherited metabolic disease specialist.level 2b, grade C
- Recommendation 7Adults with NAFLD should undergo risk stratification to determine the extent of their liver fibrosis (figures 1 and 2). First-line testing should use either fibrosis-4 (FIB-4) or NAFLD Fibrosis Score (NFS) – see table 3 (level 2b, grade B). Calculation facilities for FIB-4 and NFS should be incorporated in all primary care computer systems. (level 5, grade D) Second-line testing requires a quantitative assessment of fibrosis with tests such as serum enhanced liver fibrosis (ELF) measurements or Fibroscan/acoustic radiation force impulse (ARFI) elastography. (level 2b, grade B) We recommend that hepatologists at a local level champion this idea and discuss it with commissioners of health to deal with the burden of liver disease in their area.
- First-line testing should use either fibrosis-4 (FIB-4) or NAFLD Fibrosis Score (NFS) – see table 3 (level 2b, grade B). Calculation facilities for FIB-4 and NFS should be incorporated in all primary care computer systems.level 5, grade D
- Second-line testing requires a quantitative assessment of fibrosis with tests such as serum enhanced liver fibrosis (ELF) measurements or Fibroscan/acoustic radiation force impulse (ARFI) elastography.level 2b, grade B
- We recommend that hepatologists at a local level champion this idea and discuss it with commissioners of health to deal with the burden of liver disease in their area.
- Recommendation 8Consider referral to alcohol services for all adults with alcohol-related liver disease (ARLD) with evidence of alcohol dependency as defined by an AUDIT score of >19.level 3b, grade C
- Recommendation 9Harmful drinkers should undergo risk stratification with clinical assessment and Fibroscan/ARFI elastography. Adults should be referred to secondary care if there is evidence of advanced liver disease (features of cirrhosis or portal hypertension on imaging or from blood tests) and/or Fibroscan reading is >16 kPa (if available).level 2b, grade B
- Research Recommendation 2: Further evidence is required to establish the most cost-effective approach to identify patients with ARLD and NAFLD at risk of having advanced liver fibrosis.
- Recommendation 10Adults with abnormal liver blood tests, even with a negative extended liver aetiology screen and no risk factors for NAFLD, should be referred/discussed to a gastroenterologist with an interest in liver disease/hepatologist for further evaluation (figure 1).level 4, grade C
What constitutes a standard liver blood test panel?
- Recommendation 1Initial investigation for potential liver disease should include bilirubin, albumin, ALT, ALP and GGT, together with a full blood count if not already performed within the previous 12 months.level 2b, grade B
Response to abnormal liver blood tests: outcomes and pathways
- Recommendation 5In adults a standard liver aetiology screen should include abdominal USS, hepatitis B surface antigen, hepatitis C antibody (with follow-on polymerase chain reaction if positive), anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin and transferrin saturation.level 2b, grade C
NAFLD
- We recommend that hepatologists at a local level champion this idea and discuss it with commissioners of health to deal with the burden of liver disease in their area figures 1 and 2.
- Recommendation 7Adults with NAFLD should undergo risk stratification to determine their extent of liver fibrosis.
ARLD
- Recommendation 8Consider referral to alcohol services for all adults with ARLD with evidence of alcohol dependency as defined by an AUDIT score of >19.level 3b, grade C
Abstract
These updated guidelines on the management of abnormal liver blood tests have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines, which this document supersedes, were written in 2000 and have undergone extensive revision by members of the Guidelines Development Group (GDG). The GDG comprises representatives from patient/carer groups (British Liver Trust, Liver4life, PBC Foundation and PSC Support), elected members of the BSG liver section (including representatives from Scotland and Wales), British Association for the Study of the Liver (BASL), Specialist Advisory Committee in Clinical Biochemistry/Royal College of Pathology and Association for Clinical Biochemistry, British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN), Public Health England (implementation and screening), Royal College of General Practice, British Society of Gastrointestinal and Abdominal Radiologists (BSGAR) and Society of Acute Medicine. The quality of evidence and grading of recommendations was appraised using the AGREE II tool. These guidelines deal specifically with the management of abnormal liver blood tests in children and adults in both primary and secondary care under the following subheadings: (1) What constitutes an abnormal liver blood test? (2) What constitutes a standard liver blood test panel? (3) When should liver blood tests be checked? (4) Does the extent and duration of abnormal liver blood tests determine subsequent investigation? (5) Response to abnormal liver blood tests. They are not designed to deal with the management of the underlying liver disease.
Contents of the original publication
The section headings of the original.
- Recommendations list
- Introduction
- Guideline development
- Scope and purpose
- Guideline development group membership and stakeholder involvement
- Rigour of development
- Clarity and presentation
- Applicability
- Editorial independence and conflict of interest
- Scheduled review of guidelines
- What constitutes a liver blood test?
- What constitutes a standard liver blood test panel?
- When should liver blood tests be checked?
- Non-specific symptoms
- Evidence of chronic liver disease
- Conditions which are associated with a high risk of developing liver disease
- Use of hepatotoxic drugs
- Family history of liver diseases
- Viral hepatitis
- Presence of lifestyle risk factors associated with the development of NAFLD: obesity/type 2 diabetes
- Does the extent and duration of abnormal liver blood tests determine subsequent investigation?
- Importance of context
- Extent of abnormality
- Duration of abnormality and retesting
- Clinical pattern recognition for liver blood tests
- Response to abnormal liver blood tests: outcomes and pathways
- Approach to common conditions
- NAFLD
- ARLD
- Approach to a patient with abnormal liver blood tests and a negative extended liver aetiology screen
- Applicability
- Monitoring and/or auditing criteria
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