Abnormal LFTs: A Real Patient’s Journey Through NAFLD

08/24/23 • 13 min

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through a real-life case of a patient with abnormal Liver Function Tests and non- alcoholic fatty liver disease or NAFLD. I will describe a recommended approach to diagnose and manage them according to guidelines.

I am not giving medical advice; this podcast is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.

There is a YouTube version of this and other videos that you can access here:

· The NICE GP YouTube Channel: NICE GP - YouTube

The links to the websites that can calculate these scores are in the episode description:

· The NAFLD Fibrosis Score (NFS) is available at https://www.thecalculator.co/health/NAFLD-Fibrosis-Score-Calculator-969.html

· The Fibrosis 4 (FIB-4) Score available at https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis

You can download a summary of the episode here:

· Summary of NAFLD patient case: https://1drv.ms/b/s!AiVFJ_Uoigq0mBYIbok6DSu5vTnY?e=2W11Jd

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Transcript

Hello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom.

In today’s episode I go through a real-life case of a patient with abnormal Liver Function Tests and non- alcoholic fatty liver disease or NAFLD, describing the recommended approach for its diagnosis and management according to guidelines.

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the various guidelines consulted so you must use your own clinical judgement.

If you want to download a summary of the episode, the link is in the episode description.

Remember that there is also a YouTube version of these episodes so have a look in the episode description.

Right, so let’s get straight into it.

Our patient is a 55-year-old man of Hispanic family background who consults you following a routine blood test done one week earlier. This was a repeat blood test because 4 months previously he had been found to have a mildly raised alanine aminotransferase or ALT of 75 (NR 0-55).

The results of all his blood tests were normal with the exception of the ALT which was still high at 65.

His PMH includes:

· Prediabetes

· Hyperlipidaemia and

· Overweight with a BMI of 27.8

His only medication is atorvastatin 20 mg daily for hyperlipidaemia.

He denies alcohol excess. In fact, he is teetotal and does not drink alcohol at all. He has otherwise no symptoms.

In the previous consultation he had been told that raised liver transaminase were not uncommon during the prescribing of statins but that statins need not be stopped for raised liver transaminase levels as long as they are less than 3 times the upper limit of normal.

However, as a result of that consultation, the patient decided to stop the statin of his own accord so he has not been taking it for the last 3 months.

So, in summary, we have a patient with a background of overweight, prediabetes and dyslipidaemia with a slightly elevated ALT for 3 months without an obvious cause.

What should we do?

When we face this situation, we should consider all the possible causes and investigate them fully. But we must primarily consider the most common reason for abnormal liver blood tests in the UK, which is non-alcoholic fatty liver disease, or NAFLD.

This condition happens when excess fat builds up in the liver. But for the diagnosis to be made, we must also exclude other secondary causes.

Let’s quickly remind ourselves that NAFLD has a spectrum that goes from simple hepatic steatosis, meaning that there's fat in the liver, but it's not causing any significant inflammation or damage, to som...

I am not giving medical advice; this podcast is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.

There is a YouTube version of this and other videos that you can access here:

· The NICE GP YouTube Channel: NICE GP - YouTube

The links to the websites that can calculate these scores are in the episode description:

· The NAFLD Fibrosis Score (NFS) is available at https://www.thecalculator.co/health/NAFLD-Fibrosis-Score-Calculator-969.html

· The Fibrosis 4 (FIB-4) Score available at https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis

You can download a summary of the episode here:

· Summary of NAFLD patient case: https://1drv.ms/b/s!AiVFJ_Uoigq0mBYIbok6DSu5vTnY?e=2W11Jd

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

Free Download / Stream: https://alplus.io/halfway-through

Transcript

Hello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom.

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the various guidelines consulted so you must use your own clinical judgement.

If you want to download a summary of the episode, the link is in the episode description.

Remember that there is also a YouTube version of these episodes so have a look in the episode description.

Right, so let’s get straight into it.

The results of all his blood tests were normal with the exception of the ALT which was still high at 65.

His PMH includes:

· Prediabetes

· Hyperlipidaemia and

· Overweight with a BMI of 27.8

His only medication is atorvastatin 20 mg daily for hyperlipidaemia.

He denies alcohol excess. In fact, he is teetotal and does not drink alcohol at all. He has otherwise no symptoms.

However, as a result of that consultation, the patient decided to stop the statin of his own accord so he has not been taking it for the last 3 months.

So, in summary, we have a patient with a background of overweight, prediabetes and dyslipidaemia with a slightly elevated ALT for 3 months without an obvious cause.

What should we do?

This condition happens when excess fat builds up in the liver. But for the diagnosis to be made, we must also exclude other secondary causes.

Previous Episode

Navigating ADHD with NICE: A Practical Guide for Primary Care

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through the NICE guidelines “Attention deficit hyperactivity disorder: diagnosis and management” or NICE guideline NG87, Published in March 2018 and last updated in September 2019.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.

There is a YouTube version of this and other videos that you can access here:

· The NICE GP YouTube Channel: NICE GP - YouTube

The full NICE guidance can be found here:

· NICE Guideline NG87: https://www.nice.org.uk/guidance/ng87

· ADHD NICE CKS: https://cks.nice.org.uk/topics/attention-deficit-hyperactivity-disorder/

You can download my summaries here:

· Summary of NICE guideline NG87: https://1drv.ms/b/s!AiVFJ_Uoigq0mAekn-9SQlZAl5kD?e=WYqHT7

· Additional Clinical ADHD information: https://1drv.ms/b/s!AiVFJ_Uoigq0mAhXL3J6CRjq5QoD?e=P8cL7K

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

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Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.

In today’s episode I go through the NICE guidelines on ADHD from a primary care perspective. Make sure that you stay for the whole episode because at the end, I am going to give you additional information on the condition including possible causes, pathophysiology, prognosis and the biochemical reasons why pharmacological treatment is so beneficial in ADHD.

By the way, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.

If you want to download a copy of my summaries of the NICE guidelines or the additional clinical information, the links are in the episode description.

Remember that there is also a Youtube version of these episodes so have a look in the episode description.

Right, so let’s get straight into it.

The guideline covers the recognition, diagnosis and management of ADHD both in children and adults. It is aimed at doctors who specialise in ADHD but I have summarised it focusing on what we need to know in Primary care.

We should be aware that there is an increased prevalence of ADHD in people:

· with any mental health condition or conduct disorder

· with epilepsy or neurodevelopmental disorders

· with a FH of ADHD

· who are born preterm or have an acquired brain injury

· who are looked-after or are known to the Justice System

But we also need to remember that ADHD is under-recognised in females.

If a child has symptoms suggestive of ADHD, NICE says that we should refer to secondary care if the symptoms are severe or persist after a period of watchful waiting of up to 10 weeks with group-based ADHD-focused support. This support can be offered without waiting for a formal diagnosis.

In adults suspected of ADHD we should refer them if they have a childhood diagnosis of ADHD or without a childhood diagnosis if the symptoms are moderate or severe and cannot be explained by other psychiatric diagnoses

But a diagnosis of ADHD:

· Should be made by a specialist.

· Should not be made solely based on a rating scale.

· In children, we should assess their parents' or carers' mental health.

We should offer information about the importance of structure in daily activities and how ADHD could affect their life including relationships and driving because the diagnosis must be declared to the DVLA if it affects safe driving.

And we should involve, with consent, other healthcare professionals and educational centres so that reasonable adjustments and

Next Episode

Isolated Raised Alkaline Phosphatase - what to do?

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through a real-life case of an asymptomatic patient with an isolated raised alkaline phosphatase level. I will describe a recommended approach to investigate and manage them according to guidelines.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.

There is a YouTube version of this and other videos that you can access here:

· The NICE GP YouTube Channel: NICE GP - YouTube

You can download a summary of my summary / interpretation of the guidance here:

· My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

Free Download / Stream: https://alplus.io/halfway-through

Transcript

Interpreting Isolated Raised Alkaline Phosphatase in Asymptomatic Patients

Hello and welcome. I’m Fernando, a GP in the UK. Today, we're going to explore what to do when we encounter an isolated raised serum Alkaline Phosphatase level in an asymptomatic patient. Please like and subscribe to support the channel.

Right, so let's dive right in!

Introduction

Before we start, let’s remember that Alkaline Phosphatase is present in various tissues, including the liver, bone, kidney, intestine, and placenta. Reference ranges can vary with age and gender, so mild increases may not indicate disease.

Examples of Physiological Causes are:

· Growth spurts in adolescents

· Pregnancy in women

· Age-related increases and

· Medications like some antibiotics, antiepileptics, antihistamines, oestrogens, and steroids

Some potential causes of isolated raised serum Alkaline Phosphatase include:

· Congestive cardiac failure

· Bone diseases

· Hyperthyroidism

· End-stage renal disease

Clinical case

So, let’s have a look at our patient. She is a 49-year-old lady who had some blood tests because she was feeling a little tired. Her results came back normal with the exception of an alkaline phosphatase level of 186 (NR 30-130). Physical examination was normal and that there were no signs or symptoms of disease. In addition, she does not drink alcohol at all.

What should be our next steps?

The baseline investigations for someone with an isolated Alkaline Phosphatase are the following tests:

· Liver function tests adding GGT

· Calcium and phosphorus adding vit D and PTH

· Renal and thyroid function tests and

· A full blood count

We know that the most likely sources of Alkaline Phosphatase are either the bone or the liver. And, in order to differentiate between them, this is why we measure GGT (which is typically elevated in liver issues) and vitamin D levels and PTH levels, which may point towards bone causes.

So, for this patient we will need to repeat the Alkaline Phosphatase levels and checking gamma-GT, vitamin D and parathyroid hormone to try to determine the cause, as well as making sure that the other tests, that is, renal, and thyroid function tests, calcium, phosphorus and a full blood count have also been checked

We will talk more about our patient a little later but now let’s say that, in general terms, if all these tests come back normal, further investigations can be deferred for three months, during which Alkaline Phosphatase levels should be rechecked. Rechecking it earlier than three months is generally unnecessary unless you have specific concerns.

If Alkaline Phosphatase is raised with elevated GGT levels, it's likely of hepatic origin. Further steps that we will need to consider include:

· Abdominal ultrasound scan (to check for cholestasis and hepatic space-occupying lesions)

· Antimitochondrial antibodies test (to explore the possibility of primary biliary cirrhosis)

However, if these liver investigations are normal, and the Alkaline Phosphatase level is less than 1.5 times the upper reference limit, observation and monitor...