肝脏异常血液检查管理指南

StephenW

Guidelines on the management of abnormal liver blood tests

    Philip N Newsome1,2, Rob Cramb1, Suzanne M Davison3, John F Dillon4, Mark Foulerton5, Edmund M Godfrey6, Richard Hall7, Ulrike Harrower8, Mark Hudson9,10, Andrew Langford11, Anne Mackie8, Robert Mitchell-Thain12, Karen Sennett13,14, Nicholas C Sheron15, Julia Verne8, Martine Walmsley16, Andrew Yeoman17

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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.

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/

http://dx.doi.org/10.1136/gutjnl-2017-314924

StephenW

肝脏异常血液检查管理指南

    Philip N Newsome1,2，Rob Cramb1，Suzanne M Davison3，John F Dillon4，Mark Foulerton5，Edmund M Godfrey6，Richard Hall7，Ulrike Harrower8，Mark Hudson9,10，Andrew Langford11，Anne Mackie8，Robert Mitchell-Thain12，Karen Sennett13,14 Nicholas C Sheron15，Julia Verne8，Martine Walmsley16，Andrew Yeoman17

作者从属关系
抽象

这些更新的异常肝脏血液检测指南已经由英国肠胃病学会（BSG）的临床服务和标准委员会（BSC）在BSG肝脏部门的主持下进行委托。本文件替代的原始指导方针是2000年编写的，指南制定小组（GDG）的成员进行了广泛的修订。 GDG由来自患者/护理人员（British Liver Trust，Liver4life，PBC基金会和PSC支持），BSG肝脏科（包括来自苏格兰和威尔士的代表），英国肝脏研究协会（BASL）临床生化专业咨询委员会/英国皇家临床生物化学学会，英国儿科胃肠病学会，肝病学和营养学会（BSPGHAN），英国公共卫生（实施和筛选），英国皇家全科医学院，英国胃肠病学会和腹部放射科（BSGAR）和急性医学学会。证据的质量和建议的分级评估使用AGREE II工具。这些指南专门处理小儿和成人在以下小标题下的小学和中学护理中的异常肝脏血液检查：（1）什么构成肝脏异常检测？ （2）什么是标准的肝脏血液检测板？ （3）什么时候应该检查肝脏血液检查？ （4）肝血检测异常的程度和持续时间是否决定后续调查？ （5）对不正常的肝脏血液测试的反应。它们不是为了处理基础肝病的治疗而设计的。

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http://dx.doi.org/10.1136/gutjnl-2017-314924

StephenW

Recommendations list

    Recommendation 1: Initial 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 2: Abnormal 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 3: The 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 4: Patients 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 range (level 2b, grade B)

    Recommendation 5: In 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 6: In 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 7: Adults 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.

    Recommendation 8: Consider 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 9: Harmful 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 10: Adults 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)

StephenW

建议列表

    建议1：潜在肝脏疾病的初步调查应包括胆红素，白蛋白，丙氨酸氨基转移酶（ALT），碱性磷酸酶（ALP）和γ-谷氨酰转移酶（GGT），如果在过去12个月内尚未进行全血细胞计数。 （2b级，B级）

    研究建议1：需要进一步的证据来确定高危人群的非酒精性脂肪性肝病（NAFLD）病例发现的成本效益，然后才能被推荐。 （5级，D级）

    建议2：只有在回顾了以前的结果，过去的病史和当前的医疗状况之后，才能解释肝血检测结果异常。 （5级，D级）

    建议3：肝血检测异常的程度不一定是临床意义上的指导。这是由异常的特定分析物（参考范围以外）和临床情况决定的。 （5级，D级）

    建议4：不考虑异常的水平和持续时间，应考虑肝脏血液检查异常患者进行肝脏病因筛查。异常是指在实验室参考范围之外的分析物（2b级，B级）

    建议5：在成年人中，标准肝脏病因学筛查应包括腹部超声波扫描（USS），乙肝表面抗原，丙肝抗体（如果阳性，则采用后续聚合酶链式反应（PCR）），抗线粒体抗体，抗光滑肌肉抗体，抗核抗体，血清免疫球蛋白，同时血清铁蛋白和转铁蛋白饱和度。 （2b级，C级）

    建议6：在儿童中，铁蛋白和转铁蛋白饱和度可能不被指示，但自身抗体组应包括抗肝肾微粒体抗体和乳糜泻抗体。应包括α-1-抗胰蛋白酶水平和铜蓝蛋白（年龄> 3岁），并与适当的遗传代谢疾病专家讨论异常。 （2b级，C级）

    建议7：患有NAFLD的成年人应该进行危险分层，以确定其肝纤维化程度（图1和图2）。

        一线检测应使用纤维化-4（FIB-4）或NAFLD纤维化评分（NFS） - 见表3（2b级，B级）。 FIB-4和NFS的计算设施应纳入所有初级保健计算机系统。 （5级，D级）

        二线检测需要纤维化的定量评估，例如血清增强性肝纤维化（ELF）测量或Fibroscan /声辐射力脉冲（ARFI）弹性成像检查。 （2b级，B级）

        我们建议当地的肝病专家支持这个想法，并与卫生专员讨论，以处理他们所在地区的肝病负担。

    建议8：考虑将所有酒精相关性肝病（ARLD）成年人的酒精服务转诊，酒精依赖的证据由AUDIT评分> 19定义。 （3b级，C级）

    建议9：有害饮酒者应接受临床评估和Fibroscan / ARFI弹性成像的风险分层。如果有证据显示晚期肝病（成像或血液检查时出现肝硬化或门静脉高压）和/或Fibroscan读数大于16 kPa（如果有的话），应将成人转诊至二级保健机构。 （2b级，B级）

    研究建议2：需要进一步的证据来确定最具成本效益的方法来鉴别有晚期肝纤维化风险的ARLD和NAFLD患者。

    建议10：肝脏血液检查异常的成人，即使肝脏病变扩大阴性并且没有NAFLD的危险因素，也应该向有肝脏疾病/肝脏病学家关注的消化器官进行转诊/讨论（图1）。 （4级，C级）

StephenW

http://gut.bmj.com/content/67/1/6?etoc#block-system-main