Detecting liver disease in primary care: are we ready for change?

Liver disease is the third commonest cause of premature death in the UK, with an estimated 61 000 years of working life lost per year.1 Liver disease is often diagnosed late, when intervention is less effective. Reports from the All Party Parliamentary Hepatology Group (APPHG)2 and Lancet Liver Commission in 20143 both highlighted primary care as a setting where detection and management of liver disease require urgent improvement. The Royal College of General Practitioners (RCGP) has made liver disease a clinical priority area from April 2016 for 3 years. The liver champion’s mandate is to support primary care to work towards better identification of patients at risk of, or in the early stages of, liver disease. The goal is for GPs to intervene before liver disease becomes established. Recommendations from the Lancet commission and new National Institute for Health and Care Excellence (NICE) guidelines on cirrhosis and non-alcoholic fatty liver disease (NAFLD) signal a shift in focus around detection of liver disease.3–5 A risk factor-based approach is recommended, particularly for NAFLD and alcohol-related liver disease (ALD). It is acknowledged that normal blood tests do not exclude significant disease, and there is little mention of complex algorithms to interpret liver function tests (LFTs). The guidelines do emphasise the importance of ruling out less common, and often easily treated, causes early in the diagnostic pathway. Clinicians are advised to tailor diagnostic tests according to clinical suspicion, and refer early for viral, autoimmune, and metabolic causes of liver disease. NICE now recommends that all persistently heavy drinkers have a liver fibrosis assessment, independent of derangements in LFTs. This …