ࡱ>  Ĉbjbj *|f|f6-+ nnnnn8t. lF000W2W2W2XkZkZkZkZkZkZk$Onq~kEn2.W222~knn00ck6662>n0n0Xk62Xk66j=d(i0p)5 200? ADMIT ACUTELY or DISCUSS (*) Bilirubin 100-200? Phone or fax consultant gastro for urgent clinic visit (*) Bilirubin <100? Check Hep A/B serology, refer (*) Elevated alk phos? Normal ALT and GGT? BONY! Alk Phos protocol  ALT > 100 REFER Not ill Normal alk phos ALT < 100 Not jaundiced GP to investigate according to TRANSAMINASE PROTOCOL ABNORMAL LFT PROTOCOL (updated 2020) (*) When referring jaundiced patients please provide a detailed drug history (including all prescriptions issued within the preceding three months) and also full results of all investigations performed. On this basis we can decide on urgency required. Most, but not all, jaundiced patients will be allocated to urgent appts. GAMMA GT GGT is a sensitive marker for hepatobiliary disease, but its use is limited by poor specificity. Causes of raised GGT: Hepatobiliary disease (often with other liver enzyme abnormalities) Pancreatic disease Alcoholism Chronic obstructive pulmonary disease Renal failure Diabetes Myocardial infarction Drugs, e.g. carbamazepine, phenytoin and barbiturates and oral contraceptive pill The use of GGT is in supporting a hepatobiliary source for other raised liver enzymes, e.g. ALP. GILBERT PROTOCOL Isolated hyperbilirubinaemia This is usually Gilberts syndrome. Check: LFTs, conjugated v unconjugated bilirubin, haemoglobin, reticulocyte count. Criteria Bilirubin fluctuates but <70. (Some Gilberts patients go yellower than this but they are probably worth investigating more carefully: REFER or DISCUSS.) Bilirubin will be higher if patient fasting or during intercurrent illness. Normal FBC and reticulocyte count (to exclude haemolytic anaemia). If the patient is well and meets all the above criteria, reassure and explain the diagnosis. Give information leaflet. The patient does not need an ultrasound or referral. RAISED TRANSAMINASES Common causes: Alcohol Viral hepatitis NALFD Medications/toxins e.g. NSAIDs, antibiotics, statins, antiepileptics, antituberculosis drugs Less Common causes: Autoimmune hepatitis Haemochromatosis Alpha1-antitrypsin deficiency Wilsons disease Non-hepatic causes of raised ALT (usually small rises, <120 U/L): Coeliac disease Strenuous exercise Muscle disease Endocrine disease e.g. Hypo- and hyper-thyroidism TRANSAMINASE PROTOCOL Most patients with persistently elevated ALT have fatty liver disease due to alcohol +/- obesity +/- diabetes +/- hyperlipidaemia STEP 1 Careful alcohol history. If intake > 14u/week encourage the patient to abstain completely. Careful drug history. Stop any medications that may be relevant. Think about causes of fatty liver: diabetes, obesity, excess alcohol. ... then recheck the LFTs in 3-4 weeks. STEP 2: If transaminases > 3x normal proceed to Step 2 & 3 invx and refer If transaminases < 3x normal then .. Organise the following bloods & GP review: Weigh the patient and calculate BMI. (BMI>25 is abnormal and disease-associated.) Check BP Fasting chol:HDL & Trigs, HBa1c, FBC and Gamma GT GP Review 1 week later If alcohol or fatty infiltration likely then support lifestyle changes and re-check after 3 months. If not or if the lfts have not resolved after the 3 months of lifestyle changes then arrange the following investigations and consider referral: STEP 3: Hep B and Hep C serology Autoantibodies including AMA, ASMA, ANF Coeliac screen Immunoglobulin levels Ferritin, Alpha-1-antitrypsin Caeruloplasmin if patient aged under 35y TFT INR If ALT persistently more than twice normal consider liver ultrasound. Note - not everyone needs an ultrasound! FATTY LIVER DISEASE - NAFLD Only consider the diagnosis if . HepB, HepC, ferritin, alpha-1-antitrypsin (and caeruloplasmin if age<35) are normal Negative TTG, ANF, antimitochondrial and smooth muscle antibodies Normal platelet count and INR Normal albumin There is a reasonable cause such as obesity, alcohol, diabetes, hyperlipidaemia If ultrasound performed, there should be no splenomegaly and the liver should be either fatty (echogenic) or normal Transaminases are below 80 and there is no progressive deterioration. Address risk factors such as alcohol, obesity. Treat any concurrent conditions such as diabetes and hypertension and hyperlipidaemia. Recheck LFT in 3-4 months. Referral is not usually necessary except if they are obese, age>45 with NIDDM (as these patients are at higher risk of NASH and progression to cirrhosis). Statins are safe to prescribe if the above criteria are satisfied and the patients are low risk for NASH The majority of patients with abnormal LFTs will have NAFLD( non alcoholic fatty liver disease) or ARLD (Alcohol related liver disease). Most of these patients will need reinforcement of lifestyle advice and ongoing assessment and management in primary care, without referral to a specialist NAFLD: All patients with a clinical diagnosis of NAFLD who have had other causes of liver disease excluded should undertake a non-invasive fibrosis assessment to identify those that have advanced fibrosis. NICE recommend the enhanced liver fibrosis (ELF) test is used when people have been diagnosed with NAFLD, hwever, it is not widely available in the UK. The FIB-4 score (online calculator: GIHEP Fibrosis 4 Score), as it is the most accurate score available, and is simpler than the NAFLD fibrosis score to calculate. To calculate the FIB-4 score you need: Age AST ALT Platelet Refer for ELF test of fibroscan if FIB-4 > 1.3 in under 65s or >2.0 over 65 years. 3 yearly screen for hypertension, diabetes, dyslipidaemia and Fib-4 score Advise weight loss Aim for a sustained weight loss of least 10% of body weight (they do not need to normalise BMI), as this significantly improves fatty liver and reduces hepatic inflammation Consider orlistat as per NICE guidance to facilitate weight loss in those who fail with initial dietary changes Advise exercise at least 30 minutes three times per week (both cardiovascular and resistance exercise are beneficial, even independent of weight loss) Optimise control of diabetes Use metformin, a glitazone, or glucagon-like peptide 1 (GLP-1) analogue where possible, as these have been shown to improve fatty liver Treat hypertension Use ACEI or ARB first line (these might be anti-fibrotic) Drink sensibly, within current limits (below 14 units/week for men and women). There is no evidence at present to recommend abstinence Reduce other risk factors for vascular disease. Statins are safe in patients with NAFLD and should be prescribed as per NICE guidance Undertake an annual vascular disease risk score. Patients with NAFLD are more likely to die of cardiovascular disease than liver disease Consider referral for bariatric surgery for individuals with a BMI greater than 35 with other obesity related complications, as per NICE guidelines Calculate the FIB-4 score every three years, and refer if the FIB-4 score increases above the age related cut-off. Refer if FIB-4 > 1.3 in under 65s or >2.0 over 65 years, as the patient will need a fibroscan or ELF blood test to assess fibrosis risk and ? need for liver biopsy. ALKALINE PHOSPHATASE PROTOCOL Reference intervals contain 95% of the population, therefore 2.5% of the normal population have values above the upper reference limit. The combined analytical and biological variation for serum ALP is around 8%. For example, an ALP result of 125 U/L could be between 108 U/L and 143 U/L, spanning the upper reference limit. Minor increases in serum ALP levels are therefore more likely to be analytical, physiological, or statistical anomalies rather than indicating disease. Elevations may be physiological or pathological Common causes for raised ALP: Physiological Third trimester of pregnancy Adolescents, due to bone growth Benign, familial Pathological Bile duct obstruction Primary biliary cirrhosis Primary sclerosing cholangitis Drug induced cholestasis, e.g. anabolic steroids Metastatic liver disease Bone disease e.g Pagets Heart failure Isolated raised alk phos with normal ALT and gamma GT This suggests alk phos of bony origin. A careful medical and drug history and physical examination. Key features include abdominal pain or swelling, unintentional weight loss, back pain, bone pain, clinical indicators of liver disease, congestive cardiac failure, and end stage chronic kidney disease. If patients are asymptomatic but have raised ALP levels of unknown cause, then the test for ALP should be repeated with Gamma GT, ALT, adj calcium, (PTH?) and Vit D levels, TFTs, Cr&Es, and FBC checked within four weeks if not part of the original profile.Dont forget PSA in men, CXR in smoker, plasmaphoresis and ESR and breast exam if malignancy suspected. Also Pagets Disease in the elderly. Assuming bloods above are normal If alk phos < 1.5 Upper Limit of Normal (ULN) re-check in 1 month. Values up to 20% over ULN are likely to be statistical rather than clinical 'abnormals'. If < 1.2 x ULN recheck at 3 months and annually if stable If on repeat > 1.2 x ULN then arrange alk phos isoenzymes (and if of bony origin consider PSA in men, CXR in smokers, breast exam in women, FBC & ESR +/- myeloma screen etc) but if not of bony origin consider transaminase bloods and discuss/refer. If alkaline phosphatase >2 ULN (on a single measurement) then further investigation & probable referral is indicated. Raised Alk Phos & ALT & Gamma GT You should take a detailed history of your patients alcohol consumption, review their current and previous medications (prescribed and unprescribed), ask about any herbal/alternative remedies they might be taking, and identify any risk factors they may have for viral hepatitis. Red flag screening for possible malignancy. BP, P, BMI and abdominal examination (prostate and breast if appropriate) Primarily a hepatitis picture Gamma GT and AST if not already done FBC Ferritin/iron studies Hepatitis B, C Coeliac screen Autoimmune screen and Immunoglobulins Hba1c & Lipids ALT > 100 = refer ALT < 100 = lifestyle changes and repeat at 1 month USS if ALT remains x2 ULN but < 100 at 1 month 2ww if malignancy suspected Primarily an obstructive picture Gamma GT and AST if not already done FBC INR Ferritin/iron studies Alpha 1 antitrypsisn Ceruloplasmin if under 35 Auto-antibody screen and Immunoglobulins Routine USS if INR normal and not jaundiced or malignancy not suspected Urgent USS/referral if INR prolonged, low albumin or patient jaundiced 2ww if malignancy suspected Appendix Drugs which causes abnormal LFTs Common drug causes of raised alkaline phosphatase levels6 17 DrugsMechanismAntibiotics:Penicillin derivatives Intrahepatic cholestasisErythromycin Intrahepatic cholestasisAminoglycosides Enzyme inductionAntiepileptic drugs:Carbamazepine Intrahepatic cholestasisPhenobarbital Enzyme inductionPhenytoin Enzyme inductionAntihistamines:Cetirizine Intrahepatic cholestasisCardiovascular drugs:Captopril Intrahepatic cholestasisDiltiazem Enzyme induc"345Istu    5 6 7 J K L ` f w x y z   " $ ' l m hPs5\ h}%CJ( hBCJ( hPsCJ(jhPsCJ(UmHnHuh>h~ hPsjhPsUmHnHuC"3Isl;0 O&#$$d%d&d'd+DA/NOPQ0#g&#$$d!%d!&d!'d!+D˂/N!O!P!Q!0-g&#$$d%d&d'd+Dт/NOPQ0a&#$$d%d&d'd+DG/NOPQ  l;0&#$$d%d&d'd+DA/NOPQ0#5&#$$d!%d!&d!'d!+DA/N!O!P!Q!0&#$$d%d&d'd+DA/NOPQ0# 5&#$$d!%d!&d!'d!+DA/N!O!P!Q! 5 J ` f l;0%&#$$d!%d!&d!'d!+D!/N!O!P!Q!0&#$$d%d&d'd+D!/NOPQ0g&#$$d%d&d'd+D/NOPQ0#&#$$d!%d!&d!'d!+Dт/N!O!P!Q!f x l8884 & FoW"% &#$$d!%d!&d!'d!+D /N!O!P!Q!0%&#$$d!%d!&d!'d!+D$/N!O!P!Q!0&#$$d%d&d'd+D/NOPQ0%n&#$$d!%d!&d!'d!+D$/N!O!P!Q! ' l w x gbYYYY 7$8$H$gd<;gd<;0)&#$$d%d&d'd+D~/NOPQ0t#W &#$$d!%d!&d!'d!+D˂/N!O!P!Q!4 & FoW"% &#$$d!%d!&d!'d!+D /N!O!P!Q! m v w x 7 K W ~   b c d e f g h y z ʶhhhhhZNhRhR5CJaJh<;hR5>*CJaJ3h<;B*CJOJQJ^JaJmH nH phsH tH 9h<;h<;B*CJOJQJ^JaJmH nH phsH tH -h<;h<;B*CJaJmH nH phsH tH 'h<;B*CJaJmH nH phsH tH 3h<;h<;5>*B*CJaJmH nH phsH tH 6h<;h<;5>*B*CJ\aJmH nH phsH tH  7 K W ~   d e f g h y z  & FgdRgdRgdRgd<; 7$8$H$gd<; & F7$8$H$gd<;z ABC 167õ|||h|||||||||'h}%B*CJaJmH nH phsH tH -hRhRB*CJaJmH nH phsH tH 'hRB*CJaJmH nH phsH tH h<;hR5>*CJaJh<;h0S5>*CJaJh}%hR5\h}%h0S5CJ\aJh}%hR5CJ\aJhRhR5CJaJhRhRCJaJ(BC 17HYm & F 7$8$H$gdR & F 7$8$H$gdR 7$8$H$gdR & F 7$8$H$gdRgdR & FgdRHYm}#*/7<LMTU78`a3;TU]^jx} ˿˿˿˿˶˿˿˪˿˿˗˿˿˿˿h>CJaJh0Sh>CJaJh0ShP6CJaJh0ShPaJh0ShP5CJaJh0ShPCJaJh0ShP5>*CJaJhPs-hRhRB*CJaJmH nH phsH tH ;m}LMTU78`aU^ & FgdP & FgdP & FgdPgdPgdPgdR 7$8$H$gdR & F 7$8$H$gdR -VZ^c" & FgdPgdPh^hgdP & FgdP,-UVYZ]^bcqr!"󹫠vh0ShI3CJaJh0Sh0SCJaJh0SCJaJh<;hP>*CJaJh ;5>*CJaJh<;h<;5>*CJaJh0ShB5CJaJh0ShPCJ\aJh0Shm;5CJaJh0Shm;CJaJh0ShPCJaJh0ShP5CJaJ.IJ$$$$$$$$$&&&&&& 7$8$H$gd<;gdB$a$gd<;gd>gd1gdP & FgdP8IJLT !"####$ $/$$$$$$$$$$$ĸ|h ;hP5CJaJh>CJaJh1h ;5CJaJh15CJaJh4=CJaJh1h ;CJaJh ;h ;5CJaJh0S5CJaJh0Sh0S5CJaJh0SCJaJhPCJaJh0ShP5CJaJh0ShPCJaJ,$$$$$$4%4&&&&&&&&&''#'4'D'V'W'd'e'|''''((+(,(-(oYooooooYoooooooo*h ;h<;6CJ]aJmH nH sH tH $h ;h<;CJaJmH nH sH tH -h ;h<;B*CJaJmH nH phsH tH 0h ;h<;5B*CJaJmH nH phsH tH h ;h<;B*CJaJphh ;h@p&B*CJaJphh ;hBCJaJh ;h<;6CJaJh ;hP6CJaJh ;hQ/r>*CJaJ!&&&'#'D'V'W'e'|''''((+(,(-(.(d(e())#+ gdvCgdBgd<; & F7$8$H$gd<; & F7$8$H$gd<; 7$8$H$gd<;-(.(4(d(e((((4))))***(*)***-*/*4*B*M*S*V*W*****ĵ𗵗𗵗~m\K!h ;hvC0JB*CJaJph!h ;hSl0JB*CJaJph!h ;hQ/r0JB*CJaJph1h ;hSlB*CJH*aJeh@phr@h ;h<;B*CJaJphh ;hvCB*CJaJphh ;hQ/rB*CJaJphh ;h{HB*CJaJphh ;hvCB*CJaJph333h ;hvC5>*CJaJh ;hSlB*CJaJph**"+#+$+%+&+(+++F+G+H+++,Y,Z,,,-------ørrfRAR hT5>*B*CJ\aJph&h$hU+5>*B*CJ\aJphhPB*CJaJphh<;hPB*CJaJphh ;h{HB*CJaJphh ;hPB*CJaJphh ;hPCJaJh ;hP5>*CJaJh>5>*CJaJh ;hBCJaJh ;hBB*CJaJph!h ;h{H0JB*CJaJph!h ;hSl0JB*CJaJph#+$+%+&+G+H++,---@/A/a////////0:0 & FgdTgd$ dd[$\$gdU+ & Fdd[$\$gd{H & Fdd[$\$gdPgdPgdB----......//#///>/?/@/A/N/`/a/////////////////00#090:0A0D0S0T0_0îîß}uuuu}uu}h$CJaJhTCJaJh$h$CJaJh$h$5>*CJ\aJh$hU+B*CJaJph(hJ B*CJaJfHphq .h$h$B*CJaJfHphq &h$hU+5>*B*CJ\aJph hT5>*B*CJ\aJph._0b0c0i0j000000000000000001111.131B1C1K1O11111111111122426282庩hQ/rh0S5&h0Sh0S5>*CJOJQJ^JaJ h0S5>*CJOJQJ^JaJ hJ 5>*CJOJQJ^JaJh$h$5>*CJ\aJh$h$CJaJh$hTCJaJhTCJaJh$CJaJ.:0j0000000011C1111116282222 dt$Ifgda dh9Dgd0Sgd0S^gd0S & FgdTgd$ & FgdT822222222223 3"3T3V3n3p3r333333334444446484j4l444444444⛛jjjjjjBjhQ/rh0SB*CJOJQJU^JaJmH nH ph333sH tH hQ/rh0SmH nH sH tH ?hQ/rh0S5B*CJOJQJ\^JaJmH nH ph333sH tH MhQ/rh0SB*CJH*OJQJ^JaJeh@mH nH ph333r@sH tH 9hQ/rh0SB*CJOJQJ^JaJmH nH ph333sH tH )2222 db$Ifgdakkd$$If40 B62224` ap22"3T3V3)ekd4$$If0 B622 4` ap db$Ifgdaekd$$If0 B622 4` apV3r33333ekd$$If0 B622 4` ap db$Ifgda33444)ekd$$If0 B622 4` ap db$IfgdaekdH$$If0 B622 4` ap484j4l444ekd\$$If0 B622 4` ap db$Ifgda44444)ekdp$$If0 B622 4` ap db$Ifgdaekd$$If0 B622 4` ap4445 5 5 5"5$5V5X55555555555556| | | |"|$|F|H|||~|||||||}}}>}@}P}R}T}v}x}}}}}}}}~024fhjӫhPUBjhQ/rh0SB*CJOJQJU^JaJmH nH ph333sH tH hQ/rh0SmH nH sH tH 9hQ/rh0SB*CJOJQJ^JaJmH nH ph333sH tH B45 5 5$5V5ekd$$If0 B622 4` ap db$IfgdaV5X5555)ekd$$If0 B622 4` ap db$Ifgdaekd$$If0 B622 4` ap55555 |ekd$$If0 B622 4` ap db$IfgdationFelodipine Enzyme inductionDisease modifying agents:Penicillamine Intrahepatic cholestasisOral contraceptive pill (oestrogen) Enzyme inductionSteroids Enzyme inductionPsychotropic drugs:Monoamine oxidase inhibitors Intrahepatic cho | |$|F|H|)ekd$$If0 B622 4` ap db$Ifgdaekd"$$If0 B622 4` apH|||~||||ekd6$$If0 B622 4` ap db$Ifgda||}>}@})ekdJ $$If0 B622 4` ap db$Ifgdaekd$$If0 B622 4` ap@}T}v}x}}}ekd $$If0 B622 4` ap db$Ifgda}}})ekd $$If0 B622 4` ap db$Ifgdaekd^ $$If0 B622 4` aplestasisChlorpromazine Intrahepatic cholestasis      PAGE \* MERGEFORMAT 2 4fhjlprvx|~~||||||||dPgdc$a$gdPekdr $$If0 B622 4` ap db$Ifgda jlnprtvxz|~ˆĈǹjhJ UmHnHuhJ mHnHuhJ jhJ UhvjhvU-hchcB*CJaJmH nH ph333sH tH ˆĈdPgdc$a$(/ =!"#$% $$If!vh#v #v:V 46,5/  / 2224 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p$$If!vh#v #v:V 65/ 22 4 ` p#x002&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH 8`8 Normal_HmH sH tH 8@8  Heading 1$@&5H@H  Heading 2$$@&a$ 56>*CJ0<@<  Heading 3$@&5CJDA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List :"@: Caption$a$ 56CJ0ZC@Z Body Text Indent ^B*OJQJ^Jph4 @4 "m0Footer  9r .)!. m Page Number*W 1* cStrong5\(A( Bpop-citeBOQB Bapple-converted-space2a2 B slug-pop-date(q( Bpop-slug4U 4 Q/r0 Hyperlink >*phV^V Q/r Normal (Web)dd[$\$CJaJmH sH tH b/b RDefault 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH B/B 1highwire-cite-journalP/P 1highwire-cite-published-yearL/L 1highwire-cite-volume-issue:/: 1highwire-cite-doi</< 1highwire-cite-date44 !J Header B#:/: J Header Char mH sH tH :/!: J 0 Footer Char mH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y b-B ***-m z $-(*-_0824jĈ!#%(*+-.013:F f m&#+:022V33444V55 |H||@}}Ĉ "$&'),/2456789;<=?@ABCEG $&-!8"!"@!!(  bB  S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ?bB   S D#" ?bB   S D#" ? bB   S D#" ? bB   S D#" ? bB   S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ?bB  S D#" ? bB  S D#" ?   f W?NoArial Black#" ?  f W?NoArial Black#" ?  f W?NoArial Black#" ?  f W?NoArial Black#" ?  f W?NoArial Black#" ?  f W?NoArial Black#" ?  f W?NoArial Black#" ?  h W?YesArial Black#" ?  h W?YesArial Black#" ?  h W?YesArial Black#" ?  h W?YesArial Black#" ?  h W?YesArial Black#" ?  h W?YesArial Black#" ?   h W?YesArial Black#" ? ! h W?YesArial Black#" ?B S  ?34st56JKxyb-"D 'tBt t4D t" "t$B$t tB?Bt  tOt b t t twt2tB -"-t! ` It  ` tPptpItpYt pt pY t`pt `` tPt`  t9t PItpPt Pi!t t lc-oc-?*urn:schemas-microsoft-com:office:smarttags stockticker ௠%fijn-78? < K f n  ! !Tc xbjLU    > A B F s v w { H"M"""K#N#O#S###E$H$I$M$%%%%_(a(b(c(((6-8-9-;-<->-?-A-B-`-c- f n "#$$1%7%:(i(6-8-9-;-<->-?-A-B-`-c-333333333X(_(6-6-8-9-9-;-<->-?-A-B-`-c-X(_(6-6-8-9-9-;-<->-?-A-B-`-c-h*,{6/¥V1\BR+f&:f "Ѩ QVX c>XIzE?x2yGzE?XIi] I@ Olz`L 5g;{a76~ J w @p&n(U+F, ;<;_}<vCExKCYy]a'mQ/r wB/x41cE&>v&Sl9m0Sm;mo>$4=T{HZ1ghP=LRw }%_-PmI3l;PsSC6-8-@_(_(_(@*+,-b-@24|Unknown G.[x Times New Roman5Symbol3. .[x ArialU Arial Unicode MSArialC.,.{$ Calibri Light7..{$ Calibri?= .Cx Courier New;WingdingsA$BCambria Math"1hr6rtVw& Rw& R!4--3QHP?=L2!xxTbG Jaundice or elevated bilirubinGsobala Matthew Smithd                 Oh+'0  $0 P \ h t Jaundice or elevated bilirubinGsobalaNormalMatthew Smith5Microsoft Office Word@@~@c)@) w& ՜.+,D՜.+,T hp   NHS TrustR- Jaundice or elevated bilirubin TitleH@$<_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOncecProvisional CDM updates andy.mcelligott@bradford.nhs.ukMcElligott Andy  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHJKLMNOPRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F`)Data I1TableQqWordDocument*SummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q