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Leading article
Identification of liver disease: why and how
  1. Iain Macpherson1,2,
  2. Kushala W M Abeysekera3,
  3. Rebecca Harris4,
  4. Dina Mansour5,6,
  5. Stuart McPherson6,7,
  6. Ian Rowe8,9,
  7. William Rosenberg10,11,
  8. John F Dillon1,2,
  9. Andrew Yeoman12
  10. Specialist Interest Group in the Early Detection of Liver Disease
    1. 1Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
    2. 2Department of Gastroenterology and Hepatology, Ninewells Hospital and Medical School, Dundee, UK
    3. 3Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
    4. 4NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
    5. 5Department of Gastroenterology and Hepatology, Gateshead Health NHS Foundation Trust, Gateshead, UK
    6. 6Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
    7. 7Liver Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
    8. 8Leeds Institute for Medical Research, University of Leeds, Leeds, UK
    9. 9Leeds Liver Unit, St James's University Hospital, Leeds, UK
    10. 10Institute for Liver and Digestive Health, University College London Division of Medicine, London, UK
    11. 11Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
    12. 12Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, UK
    1. Correspondence to Dr Iain Macpherson, Division of Molecular and Clinical Medicine, University of Dundee, Dundee DD1 9SY, UK; iain.macpherson5{at}nhs.scot

    Abstract

    Mortality from chronic liver disease (CLD) in the UK has increased by over 400% since 1970, driven by alcohol, non-alcoholic fatty liver disease and hepatitis C virus, the natural histories of which can all be improved by early intervention. Patients often present with advanced disease, which would be preventable if diagnosed earlier and lifestyle change opportunities offered.

    Liver function tests (LFTs) are very commonly measured. Approximately 20% are abnormal, yet the majority are not investigated according to guidelines. However, investigating all abnormal LFTs to identify early liver disease would overwhelm services. Recently, several diagnostic pathways have been implemented across the country; some focus on abnormal LFTs and some on stratifying at-risk populations.

    This review will collate the evidence on the size of the problem and the challenges it poses. We will discuss the limitations and restrictions within systems that limit the responses available, review the current pathways being evaluated and piloted in the UK, and explore the arguments for and against LFT-based approaches and ‘case-finding strategies’ in the community diagnosis of liver disease. Furthermore, the role of fibrosis assessment methods (including scoring systems such as Fibrosis-4 (FIB-4) index, the enhanced liver fibrosis test and elastography) within these pathways will also be discussed.

    In conclusion, this review aims to establish some principles which, if adopted, are likely to improve the diagnosis of advanced liver disease, and identify the areas of contention for further research, in order to establish the most effective community detection models of liver disease.

    • chronic liver disease
    • screening
    • liver function test
    • primary care

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    Footnotes

    • Twitter @drdina_mansour, @stumcp, @GwentLiverUnit

    • Collaborators Specialist Interest Group in the Early Detection of Liver Disease Members: John F Dillon, Andrew Yeoman, Kushala Abeysekera, William Alazawi, Richard Aspinall, Paul N Brennan, Johnny Cash, Matthew Cramp, Tim Cross, Kate Glyn-Owen, Fiona Gordon, Neil Guha, Rebecca Harris, Helen Jarvis, Moby Joseph, Iain Macpherson, Dina Mansour, Stuart McPherson, Joanne Morling, Philip Newsome, James Orr, Richard Parker, William Rosenberg, Ian Rowe, Ankur Srivastava, Leanne Stratton, Emmanouil Tsochatzis, Fidan Yousuf.

    • Contributors IM took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests KWMA has received lecture fees from Intercept Pharma and a grant from the David Telling Charitable Trust unrelated to this work, DM has received consultancy fees from Intercept Pharma unrelated to this work, SM has received personal fees from MSD, AbbVie and Gilead unrelated to this work, IR has received consultancy fees from Roche unrelated to this work, WR has received speakers fees and research support from Siemens Healthineers unrelated to this work, and is an inventor of the Enhanced Liver Fibrosis Score but has not received royalties in this regard. No other authors have any competing interests related to this work.

    • Provenance and peer review Commissioned; externally peer reviewed.