Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • gastrointestinal bleeding
  • acute liver failure
  • sepsis in a patient with cirrhosis
  • severe encephalopathy in a patient with liver disease

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Women's and Children's Health Network

Exclusions

Patients with Fibrosis-4 (FIB-4) index risk score less than 1.3 can be considered as low risk and safely managed in primary care

Triage categories

Category 1 - appointment clinically indicated within 30 days

  • fatty liver cirrhosis with evidence of liver decompensation, including:
    • jaundice and/or
    • ascites
  • encephalopathy

Category 2 — appointment clinically indicated within 90 days

  • fatty liver cirrhosis without evidence of liver decompensation
  • fibrosis-4 (FIB-4) index risk score greater than 1.3

Category 3 — appointment clinically indicated within 365 days

  • nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

History

  • past medical/surgical history
  • family history of liver disease or diabetes
  • onset, duration, and progression of symptoms
  • current/previous medications and dosages, including supplements
  • use/frequency of alcohol, tobacco, and other drugs
  • allergies and sensitivities
  • management history including treatments trialled/implemented prior to referral
  • identification as Aboriginal and/or Torres Strait Islander

Examination

  • abdominal examination results
  • features of hepatic failure, e.g. jaundice, ascites and/or encephalopathy
  • height/weight/body mass index (BMI)

Investigations

  • fibrosis-4 (FIB-4) index risk score
  • complete blood examination (CBE)
  • liver function test (LFT)
  • urea, electrolyte, and creatinine (UEC)
  • fasting blood glucose
  • glycated haemoglobin test (HbA1c)
  • lipid studies
  • iron studies
  • international normalised ratio (INR)
  • hepatitis B serology (HBV)
    • hepatitis B surface antigen
    • hepatitis B surface antibody
    • hepatitis B core antibody
  • hepatitis C serology (HCV): hepatitis C antibody with a request for pathology to reflexively test for HCV RNA if positive antibody result
  • antinuclear antibody test (ANA)
  • antimitochondrial antibody test (AMA)
  • smooth muscle antibody (SMA)
  • immunoglobulin G antibody (IgG)
  • haemochromatosis gene (HFE) test (if elevated ferritin and transferrin saturation)
  • c-reactive protein (CRP)
  • upper abdominal ultrasound (US)

Additional information to assist triage categorisation

  • liver elastography and/or other relevant imaging reports
  • vitamin studies (vitamin A, vitamin D, vitamin E)

Clinical management advice

The cornerstone of management for fatty liver disease remains lifestyle modification, targeting diet, physical activity, and behavioural therapy, ideally with input from a multidisciplinary team comprised of allied health clinicians, including dietitian, exercise physiologist, psychologists.

Optimisation of chronic medical conditions should be considered as part of initial assessment and management.

Metabolic dysfunction–associated fatty liver disease (MAFLD) has been suggested as a more appropriate term than non-alcoholic fatty liver disease (NAFLD), as it more accurately reflects the pathogenesis of this condition.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but may not fit the criteria provided, you are encouraged to contact the specialist team to discuss your concerns.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.