Management of Deranged Liver Function Tests and Thrombocytopenia

Immediate Assessment and Red Flags

The American Gastroenterological Association recommends urgent referral to secondary care if unexplained jaundice, suspected hepatobiliary malignancy, or synthetic liver failure are present 1, 2
Urgent referral to secondary care is required if suspicion of hepatic or biliary malignancy is present 1, 2
Evidence of synthetic liver failure, such as prolonged INR or hypoalbuminemia, requires urgent referral to secondary care 2
Marked derangement of liver blood tests with clinical instability requires urgent referral to secondary care 2

The European Association for the Study of the Liver recommends obtaining specific information, including alcohol consumption, quantified as units per week, with harmful drinking defined as ≥50 units/week in men and ≥35 units/week in women 1
A medication review, including all prescribed medications, over-the-counter drugs, and herbal supplements, is essential to identify potential causes of liver injury 4
Risk factors for viral hepatitis, such as country of origin, injection drug use history, and incarceration history, should be assessed 5, 6
Metabolic risk factors, including BMI >25, type 2 diabetes, and features of metabolic syndrome, should be evaluated 1, 2

The American Association for the Study of Liver Diseases recommends ordering a complete blood count with full differential, comprehensive metabolic panel, abdominal ultrasound, hepatitis B surface antigen, hepatitis C antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, and simultaneous serum ferritin and transferrin saturation simultaneously 1, 7
If ALT >1000 U/L, additional testing, including hepatitis A serology and hepatitis E serology, should be performed 5

For suspected NAFLD, the American Gastroenterological Association recommends calculating FIB-4 or NAFLD Fibrosis Score (NFS) as first-line fibrosis risk stratification 1
If metabolic risk factors are present, consider referral for further fibrosis evaluation if scores suggest advanced disease 1
For alcohol-related liver disease, refer to alcohol services for dependency treatment and perform risk stratification with Fibroscan/ARFI elastography 1

The American Association for the Study of Liver Diseases recommends initiating antiviral therapy to prevent HBV reactivation and hepatitis flare if hepatitis B surface antigen positive and systemic corticosteroids or immunosuppressants are planned for ≥7 days 7
If drug-induced liver injury is suspected, review timing of medication use relative to liver abnormality development, exercise clinical judgment regarding major contributor, and consider discontinuation of potentially hepatotoxic medications 4
Statins rarely cause liver injury and are safe in patients with pre-existing abnormal liver enzymes 4

The European Association for the Study of the Liver recommends referring patients with positive hepatitis B or C serology, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, abnormal liver blood tests with negative extended aetiology screen and no NAFLD risk factors, or evidence of advanced liver disease or cirrhosis to gastroenterology/hepatology 1, 2, 3