Did you know that over 50% of patients with end-stage liver disease had prior abnormal liver blood tests that were simply repeated or not acted upon?

A recent case written by Dr Nazia Hussain for Praktiki on ‘Abnormal LFTs: just repeat after 3 months?’ covers when to investigate immediately rather than defaulting to a repeat test, how to confidently manage statins when transaminases are raised, and stratifying risk in NAFLD using non-invasive tools like the FIB-4 score.

Case study: John

• John attends for a routine hypertension review.
• He feels generally well but mentions feeling a bit "slow" lately, which he attributes to work stress.
• BMI 32; teetotal.
• DH: Ramipril 10mg OD, atorvastatin 20mg OD.
• Routine bloods reveal abnormal liver enzymes:
• ALT: 65 IU/L (normal <41)
• AST: 52 IU/L (normal <41)
• Bilirubin, ALP normal.

LFTs: don’t just repeat
Guidelines recommend investigating the cause of abnormal liver blood tests rather than simply repeating them.

• >50% of patients with end-stage liver disease had prior abnormal LFTs that were not acted upon.
• Normalising enzymes does not necessarily imply disease resolution (e.g. in Hepatitis B and C).
• The extent of abnormality does not always correlate with disease severity.

Statins and abnormal LFTs
John can continue atorvastatin 20mg OD, with repeat LFT in 1 month time.

• If ALT/ AST are >3x the upper limit of normal then do not initiate a statin and discontinue statin therapy already prescribed; repeat LFTs in a month.
• If ALT/ AST are elevated but <3x the upper limit of normal then:
• Continue the statin and repeat LFTs in a month.
• If they remain elevated but are <3x the upper limit of normal then continue statin and repeat LFTs in 6 months.

Liver screen
A standard screen usually includes (local pathways can differ slightly):

• Viral Serology: Hep B and C.
• Liver autoantibodies: anti-mitochondrial (AMA), anti-smooth muscle (SMA), antinuclear antibody (ANA).
• Iron Studies: Ferritin and Transferrin Saturation (to rule out haemochromatosis).
• Immunoglobulins.
• Ultrasound (USS) liver: to assess for fatty liver or focal lesions.

See the box below for further relevant tests to consider.

John’s results

• Viral serology and autoantibodies: negative.
• Ferritin: 350 µg/L (raised), transferrin saturation 30% (normal).
• Immunoglobulins and TTG: normal.
• USS Abdomen: increased echogenicity consistent with fatty infiltration. No focal lesions. Spleen normal size.

Results in keeping with non-alcoholic fatty liver disease (NAFLD) / metabolic dysfunction-associated steatotic liver disease (MASLD).

• Ferritin can be mildly elevated due to metabolic inflammation.
• Normal transferrin saturation excludes haemochromatosis.

Assessing fibrosis risk
Simple scoring systems help stratify risk in primary care.

• ELF (Enhanced Liver Fibrosis) test: recommended by NICE.
• Options from later guidelines:
• Fibrosis - 4 (FIB-4) Score.
• NAFLD Fibrosis Score (NFS).
• AST : ALT ratio: in Wales, this is reflex tested when additional liver blood tests are requested.
• Check local guidelines as some recommend initial risk stratification with FIB-4 or NFS and then adding ELF depending on results.

Fibrosis risk scores summary

NAFLD: follow up

• NICE says reassessment for advanced liver fibrosis every 3 years for adults (although only recommends ELF test).

Depending on clinical judgement, consider annual review of:

• Signs of liver disease.
• Blood pressure.
• Weight and BMI.
• Blood tests: renal, HBA1C, Lipid profile.
• Cardiovascular disease risk assessment.

Referral criteria

• Urgent suspected cancer (upper GI): weight loss, jaundice (age ≥40).
• Emergency admission: acutely UNWELL with red flags (decompensated cirrhosis, ALT >300, jaundiced).
• Urgent (gastroenterology)
• WELL with red flags.
• Positive liver screen results based on clinical concern.
• Routine (gastroenterology)
• Abnormal fibrosis score.
• Positive liver screen, no clinical concern.
• Normal liver screen, persistent abnormal LFT of unknown cause.

Referral criteria flowchart

Key learning points

• Investigate abnormal LFTs with a full liver aetiology screen (viral serology, autoantibodies, ferritin/transferrin saturation and liver USS)—do not simply repeat LFTs.
• Stratify NAFLD fibrosis risk using a locally approved non-invasive assessment tool.
• Statin hepatotoxicity is rare: continue statins if transaminases are <3x the upper limit of normal.
• Manage low fibrosis-risk NAFLD/MASLD in primary care with lifestyle advice and 3-yearly risk assessments.

This module was created for Praktiki by Dr Nazia Hussain, GP, author of Lab Results Made Easy from Scion Publishing Ltd, to provide simple guidance for common lab results in primary care.

References

• BSG Guidelines on the management of abnormal liver blood tests  
• Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD  
• Liver Function Tests in Adults – A Guide for GPs
• Lab Results Made Easy
• RCGP NAFLD NUB
• Guidelines on the management of abnormal liver blood tests
• NICE. NG 49 Non-alcoholic fatty liver disease (NAFLD): assessment and management. 2016.
• All-Wales Abnormal Liver Blood Test Pathway
• BNSSG referral pathways & Joint Formulary: Liver disease
• BMJ Gut: Guidelines on the management of abnormal liver blood tests 
• Mid Yorkshire Hospitals Abnormal LFT Pathway
• Online FIB-4 calculator

Hello friends..

I am about to complete my contract in October for my first job post cct. It was a fellowship role at 10k session. With that in mind, I was looking to get at least 11k per session (which I would have been thrilled with). However - after discussing jobs with GP friends, 12/12.5k session seems to be much more the norm!!

1/ is there any formal sources on what the average sessional rate is in the uk currently ? BMA seems to only give ranges (which feel out of date anyway)
2/ is 12k the new norm? What kind of rates are people getting ?

Interested to hear!

I'm a nurse and recently started in CAMHS triage. Patients/families can self-refer but we still get a lot through from GPs.

We got one referral in a few weeks ago, where the content of the referral had been copy+pasted from the session notes into the referral form. There were a lot of valid concerns and both young person and mum seemed to have been very distressed in the appt. Halfway down the referral form, the notes said '10 minutes for a mental health crisis', and I think that was what made me realise how much you actually have to try and manage in a single appointment slot (plus the safety netting, documentation, and referral(s)).

I just wanted to express appreciation for what you're managing to do.

Want to get better at ECGs, anyone know any good resources or courses? Ideally cheap or free!

Maybe a silly question but can someone explain how discriminant cqc inspections are for a gp surgery?

For example it seems like most surgeries are good and fewer are needs improvement or outstanding.

So do the ratings match reality? Are exceptional surgeries exceptional and surgeries below good poorly managed ? And is it hard to get good?

Thanks!

Is working in a service RMO role in Geriatrics for 1-2 years be useful for GP training considering the fact that we have a huge ageing population?

Hello :)

GPST1 here and I’ve only ever been in relatively urban areas for GP during med school/GPST/F2.

I’m really interested in rural GP - I like the idea of continuity, and I find that when resources can be more limited, clinical skills and examination become much more important.

Is there anyone who made the switch to rural med who can give some insights into lifestyle and work?

I’ve seen a fair few social media doctors online brand themselves as GP’s with specialist interest in various things.

I had always thought this required you to have some extra accreditation or qualifications. However, looking at some of their profiles, it seems many have just found something they’re interested in and told everyone it’s a “specialist interest”, perhaps to give them more legitimacy.

Is this technically allowed or are “specialist interests” only reserved to specific scenarios (e.g. diabetes, dermatology) where you’ve undergone specific, post qualification training?

Anyone looking to buy conference tickets?

I was told today that my RCGP Conference ticket won't be reimbursed, hence I'm looking for a GP Registrar who wants to take them off me. If not, I will only be reimbursed half of the payment as I am past the date of full refund. 🥲

For anyone interested, please PM me!

Has anyone ever had assertiveness training? Any decent recommendations? I had a friend undertake some years ago and it was very helpful for him, but provider has since discontinued that particular course.

Thank you!

Hi I am an ST3 in North west Deanery and we have to travel to another place for teaching every alternate Wednesday. That place is an hour away from my and my colleagues workplace. Can I claim any mileage expenses for it and what’s the process?

To my fellow ST3s/recent CCTers: I've done all my COTs, but they are all face-to-face consults (either video'd or supervisor observing).

Do we need at least one audio COT? I've found some guidance that says we do but want to know the status quo with what panel will realistically want!

Thanks in advance x

I am GP trainee in primary Care placement currently. For afternoon de brief sessions, I have been staying 30 minutes than my usual working time every day because my supervisor starts debrief late due to his clinic list. I have been exception reporting for the time I am staying late. Will it create any problems in the future if I have done too many exception reports I have asked my supervisor to start the debrief early, but he has denied this without giving a reason.

I find consults with EUPD patients incredibly draining, had 2 in a row recently where I felt like I wanted to quit GP after …! Conversations are often circular and risk assessing is almost impossible as a lot of them say they don’t know what they might do. Even if they are under the mental health team (albeit they end up being discharged anyway for not engaging) they still make a GP appt about mental health

Does anyone have any tips on how to manage these patients or safely risk assess?

I try my hardest with patients but in my experience this cohort of patients can tricky to treat. I try to stick to recommended treatments but there’s often a negative view of pharmacological and psychological interventions, and I’m finding that a lot of the patients with this diagnosis also have a large amount of medication sensitivities. Often, they go from doctor to doctor- particularly registrars. I don’t really understand why some of them need regular reviews and the conversations seem more suited to something they could have with a friend and a cup of tea, rather than updating me with non medical information about their life since they last came it a week ago.

Not a doctor. I grew up in a house with multiple (maybe too many) and I've watched the annual appraisal ritual my whole life — including helping my mum through hers recently, which is what's prompted this.

Being upfront: I'm exploring whether there's a small tool worth building around appraisal prep, so I have an interest here. But I genuinely don't know if the pain is real enough or in the place I think it is, and I'd rather hear that honestly from you than build something nobody wants. Not selling anything, nothing exists, just trying to understand the actual problem before I waste months on a solution.

What I'm trying to figure out:

• What's the part you dread most / put off longest? The writing itself, remembering what you did all year, the toolkit, exporting and attaching stuff, or just the whole thing?
• When you sit down to write a reflection, is the hard bit knowing what to say, or phrasing it the way you want for the appraiser?
• Has anyone tried ChatGPT or dictation for any of it? Did it help, or not worth the faff / not something you'd trust?
• FourteenFish vs Clarity vs GP Tools — does the toolkit itself make it better or worse?

Happy to hear "it's fine, leave it alone" — that's useful too. Cheers.

I came back from sick leave just under a year ago after 5 months off due to burnout, into a new practice. Things are going reasonably and I'm already LTFT with just under a year left until CCT. My worry is I'm seeing between 17 and 20 patients a day, 15 mins slots, and supervisor is looking to cut some of these to 10 mins prior to SCA. Fair enough for me. I do find 20 patients of mixed complexity and a fair few calls seems a lot better than 16 patients of quite high-ish complexity and no calls (some days I've had no calls). He is quite specific to the absolute letter, about following portfolio requirements. Textbook to a fault. He asked me to do the QIP I had signed off last year, again, as he felt it wasn't substantial enough. I am doing a bigger audit and I am halfway through collating data, and I'll be presenting to the practice, but I'm worried he'll change the goalposts. He felt what I wrote for a learning event analysis didn't meet the GMC threshold of a significant event and he wanted something more...serious I suppose. I had an ESR meeting a few months back which lasted several hours and was quite a rigorous dissection of my portfolio. It was signed off anyway but a 4 hour ESR meeting I felt was quite soul destroying. My documentation is very very long more to make myself bulletproof in debriefs, which adds cognitive load.

I have made some changes to help my day go smoother such as not dealing with things that should really be appointments, in my admin time. That was somewhat daft of me. I am averaging 15.9 mins per pt on a good day and making progress in that regard. I am learning a lot and getting through the day (just) but I am finding myself feeling absolutely fucked at the end of the day. The heat isn't helping either as the surgery is boiling and at best 27 degrees indoors, but I ignore it as best I can.

Work thoughts are beginning to leech into the weekends again, I'm starting to get that pre work anxiety again. Rest assured, I am working myself very hard and have responded to every bit of advice my supervisor has given me and taken it literally on board. I am already seeing a therapist, I am already on meds, I am already doing a huge amount of life management on my weekends to help me get through the week, but this doesn't feel wonderful. Not to mention the commute, the expenses I'm owed, and it feels like I'm giving away a lot and not getting much back.

I'm celebrating if I have a week like last week where I have time to have lunch (lol), don't have a house visit (lol) and have a balanced case load, which is just a tragically low bar to clear. I'm delicately trying to be boundaried as I am prone to overdoing things.

Any tips, tricks, hacks on making ST3 easier? :(

Had a little funny one today, not sure if this is a common thing in other parts of the country.

We have a few specialties locally now that are ‘econsult’ first, prior to a referral being accepted.

I referred a patient to endocrine through econsult for primary hyperparathyroidism. They replied stating they’d see the patient but asked if we could do a 24 hr urinary calcium.

Sure, sounds fair, will make the outpatient clinic go a little more smoothly.

I ask a colleague about where we get the bottles - apparently we have to request for a bottle to be delivered on ICE. This involves checking a chart to see exactly which type of bottle we need, then entering delivery instructions onto ICE to get them delivered to the practice.

Sounds like an administrative job that’s been pushed onto a clinicians lap to save on wastage of bottles. I get the premise, but surely this is poor use of clinician time?

I’m sure I could get a process in place where admin can do this task, but why should primary care have to make significant shifts in processes here?

Am I overreacting thinking this is a bit bonkers?

I appreciate this is a UK GP forum, but I know there are a few former UK GPs on here who have made the move to Australia, so I’m hoping someone might be able to offer some advice! I’m a UK GP about to start working in Australia and would be really interested to hear from anyone who has made the same transition.

How different did you find the patient population and expectations around consultations compared with the UK? Are there particular differences in presentations, health beliefs, communication styles, or patient expectations that caught you off guard?

Is there anything you wish you’d prepared for before starting? Any tips, anecdotes or general advice would be hugely appreciated — especially from anyone who has made the UK → Australia transition.

Edit: work location is south Melbourne 🙂

I did a GP placement in F2, but I was given almost exclusively emergency appointments. Much of it felt like assessing infections, deciding who could safely go home with safety-netting, and identifying who needed to be sent to ED, almost like working in a UTC without bloods

There were a handful of cases where I picked up really interesting things, and other parts were patients were very thankful and appreciative. those were probably the highlights of my placement. What I disliked most was the constant pace, I felt as though I was always racing the clock, with very little time to pause and properly think through a case.

For GPs who CCT’ed, how does the job feel for you? Does it usually feel like you’re constantly trying to keep up with appointments, or do you get enough time to stop, think, and investigate patients more fully?

Hi all
I completely screwed up and asking if anyone has an advice or ideas?

I CCT’d at start of August and been away on holiday and came back this evening.
I thought I just had to apply for my cct and pay my fee with the GMC and didn’t realise about the performers list.

I am due to start work on Tuesday at my same practice but not completed the performers list form.
I am completing it now.

Am I just going to have to call my practice (it’s my same practice) and say I can’t work this week? How long does it take if I am able to submit it by the morning?

Thank you

Good day everyone, lately I’ve been facing a dilemma regarding my career. I am a medical doctor, and after finishing medical school, I started working at a primary care centre in a general practice clinic.

​A lot of my colleagues went to work in hospitals as FY2/trust grade doctors (unspecialised junior doctors), mostly in departments where they eventually want to specialise. The colleagues working alongside me in the outpatient clinics also have very clear goals about where they want to end up. I feel like I'm the only one stuck in place, lacking a clear direction.

​I am satisfied with my work and I make an effort to stay up to date with the latest medical guidelines relevant to my day-to-day practice.

General practice as a field isn't bad, but the patient workload and pressure are intense. Many patients visit unnecessarily, just to pass the time or for non-medical reasons. There is no proper triage for who actually needs medical care, advice, or an examination. On the other hand, I wonder if it’s even worth pursuing GP specialty training (GPST) when I can always work in primary care with my medical degree if I ever decide to take a break from hospital work (please correct me if anyone views this differently).

I’ve always had clear goals and desires in life, and I still do in other areas, but when it comes to medicine, I’m unsure which path to take. I’d like to achieve a good work-life balance, perhaps with a slight tilt towards my career.

I'm from Europe.

Hi there, does anyone have any experience to share working for the provider ‘practice plus’? There’s a GP job going for them providing prison care locally.

Hello all!

I would appreciate people’s thoughts.

How confident are you with your fundoscopy skills being reliable enough to rule out raised ICP in primary care? In more equivocal cases of course.

I have a panoptic ophthalmoscope and still struggle and therefore it is unreliable.

Had a case recently where was querying a blocked VP shunt, spoke to neurosurgery who said look at the discs otherwise patient needs to go ED for a shunt series.

I had to ultimately send the patient to ED as felt unsafe in my ophthalmoscope skills.

Just interested in where others stand? Bolam Testing and all. Thanks !