Tutorial presented by Dr Andrew Yeoman, National Liver Clinical Lead and Consultant Hepatologist, Aneurin Bevan University Health Board

Step 2 of the All-Wales Abnormal Liver Blood tests pathway is to differentiate between patients with predominantly cholestatic abnormalities and predominantly hepatitic abnormalities, and perform further investigations.

• Cholestatic liver blood tests have a predominantly abnormal ALP, above the upper limit of normal, and these patients should have imaging and a liver aetiological screen to identify the underlying cause.
• Hepatitic liver blood tests have a predominantly abnormal ALT, above the upper limit of normal and more abnormal than the ALP, and these patients should have a repeat test to identify any transient acute abnormalities, a FRA, and a liver aetiological screen.

Having undertaken investigations that are relevant to the underlying liver disease, patients will be divided into those with no abnormal findings and those with abnormal findings and should be referred to hepatology or managed in primary care accordingly.

Some patients who have unremarkable findings on further investigations may still warrant a referral to hepatology if the clinical index of suspicion is high.