Nurse-led inpatient fibrosis assessment for patients with suspected alcohol related liver disease and previous poor engagement with services

ABSTRACT

Background and aims: Identification and staging of fibrosis is a critical part of assessment for people with alcohol related liver disease. For those presenting acutely in hospital, staging tests are frequently deferred until out-patient review. However, engagement with elective services is often poor in those with ongoing alcohol use, leaving investigation incomplete and the need for hepatology followup uncertain. To mitigate this, we instituted an in-patient fibrosis assessment service within our Alcohol Care Team (ACT) and evaluated the results. Method: From February 2020-October 2021, we sought out acutely admitted patients who had been identified as drinking excessively (more than the United Kingdom guidance of 14 units/week) and who had previously not engaged with the ACT for staging of suspected liver disease. All patients were staged by Fibroscan (Echosens). Enhanced Liver Fibrosis (ELF) test was additionally performed when it became available at our facility. Implementation of the pilot was delayed and disrupted due to the impact of Covid-19 on service delivery, with most patients identified from March 2021 onwards. Results: 70 patients were identified-45 (64%) male, 25 (36%) female, with median age 53 years (range 25–80 yr). Fibroscan results ranged from 3.4 kPa–75 kPa. 40 (57%)were normal (<7.0 kPa),13 (19%) F1–F3 (7.1 kPa–18.5 kPa) and 17 (24%) F4 (>18.5 kPa). ELF was performed in 32 (46%) patients;19 (59%) showed severe fibrosis (score 9.8–14.3) and 13 (41%) moderate fibrosis (score 7.9–9.6). ELF and Fibroscan werewell matched for identification of cirrhosis, with cirrhotic range Fibroscan results only found in those with severe fibrosis on ELF, suggesting either test could be used to rule out cirrhosis in this group. Following Fibroscan assessment, annual ACT follow-up was arranged for all patients in F1–F3 range, and the 25 patients with a normal Fibroscan who continued to drink excessively. Patients with any results in the cirrhotic rangewere referred to hepatology for ongoing management. Conclusion: By performing fibrosis assessment during an inpatient stay, wewere able to exclude significant liver disease in many people we had previously been unable to stage, providing important information to the patient and avoiding unnecessary hepatology follow-up. Provision of in-patient non-invasive fibrosis assessment may therefore be a valuable addition to hospital ACT services for capturing patients who poorly engage.