This blog post comes from; Andrew Wragg, Patient and Public Involvement & Engagement Facilitator, Research & Innovation Nottingham University Hospitals, NIHR Nottingham Digestive Diseases BR, Nottingham University Hospitals NHS Trust and the University of Nottingham.

Liver disease is a growing health burden and is currently the third leading cause of premature death in the UK with the death rate continuing to rise. This is despite the fact that the majority of liver disease results from lifestyle related risk factors including excess alcohol use, obesity (and related type 2 diabetes) and intravenous drug use.

Why are we not identifying liver disease earlier?
In primary care, we rely upon liver function tests (LFTs) to detect patients requiring further investigation for possible liver disease. This is an inadequate approach; LFTs are woeful at detecting liver disease before patients have symptoms. Subsequently in the UK, 50% of patients with cirrhosis are diagnosed for the first time when hospitalised with symptoms of liver failure resulting in a reduced quality of life and an increased risk of death and associated healthcare cost. In contrast, many patients with abnormal LFTs do not have liver disease, resulting in anxiety for patients who require unnecessary invasive investigations.
There are newer non-invasive tests which detect liver disease more accurately than traditional blood tests, and importantly avoid the need for invasive investigations. However, at present these new tests are not widely used within the community to identify liver disease.

What is this new non-invasive test?
Fibroscan is an imaging test which measures liver stiffness, and can detect earlier stages of liver disease before patients develop symptoms. We have piloted an investigation pathway using a simple blood test and a Fibroscan in the community as part of a collaboration between the Nottingham Digestive Diseases Biomedical Research Unit and East Midlands Academic Health Science Network.

Out of a population of 10,479 adult patients within two GP practices in Rushcliffe, Nottingham, 920 patients were identified due to hazardous alcohol use or type 2 diabetes. From these, 517 patients underwent a simple blood test and 378 patients identified to have an abnormal result subsequently underwent a Fibroscan. A significant proportion had results compatible with significant liver disease (26.8%), and 11 new cases of liver cirrhosis (advanced liver disease) were detected. This is a 2.4 fold increase of cirrhosis in the participating GP practices. Importantly, 72% of the patients with an abnormal Fibroscan, and 91% of patients diagnosed with cirrhosis, had normal LFTs and would not have been detected through standard care.

Feedback from the patients participating in the pathway was very positive, with more than 90% of patients stating that they would definitely recommend the service to their family and friends.

What next?
The future challenge is to implement the community based-liver pathway into multiple GP practices in Nottingham. With earlier and more accurate identification of liver disease a targeted approach to manage patients' lifestyle related risk factors could be implemented resulting in reduced progression of liver disease, and consequently a reduction in liver-related deaths and healthcare costs. We would like to work with GPs, patients and the clinical commissioning groups (CCGs) to raise both the profile of liver disease and improve the diagnosis and management of this condition.

Any questions related to this article, email This email address is being protected from spambots. You need JavaScript enabled to view it. and we will get back to you as soon as possible. You can also read more about the EMAHSN's Scarred Liver project.