A 62-year-old woman is evaluated during a follow-up appointment 12 weeks after she completed treatment for genotype 1a hepatitis C virus (HCV) infection. She has Child-Turcotte-Pugh Class A cirrhosis (well-compensated cirrhosis). Small esophageal varices were noted on upper endoscopy 1 year earlier.
On physical examination, vital signs are normal; BMI is 26. Palmar erythema, spider angiomata over the chest, a firm liver edge 3 cm below the costal margin, and a palpable spleen tip are noted. The examination is otherwise normal.
Her HCV RNA is undetectable and her calculated Model for End-Stage Liver Disease score is 8.
Which of the following is the most appropriate management for this patient?
A. Liver transplantation evaluation
B. Measurement of HCV RNA in 12 weeks
C. Ultrasonography of the liver every 6 months
D. Upper endoscopy
MKSAP Answer and Critique
The correct answer is C. Ultrasonography of the liver every 6 months. This content is available to MKSAP 18 subscribers as Question 96 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate management for this patient is ultrasonography screening for hepatocellular carcinoma every 6 months. Liver diseases associated with the highest risk for hepatocellular carcinoma are hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and hemochromatosis. Approximately 80% of hepatocellular carcinoma occurs in patients with cirrhosis, but it can develop in the absence of cirrhosis in patients with HBV infection. All patients with cirrhosis from any cause should undergo liver ultrasonography every 6 months with or without α-fetoprotein measurement. Patients with HCV infection who achieve sustained virologic response (which is synonymous with virologic cure) have a reduced risk for hepatocellular carcinoma. Regardless of virologic response, surveillance is recommended for patients with stage 3 or stage 4 fibrosis (stage 4 fibrosis signifies cirrhosis, as found in this patient).
Liver transplantation evaluation is not indicated for this patient with Child-Turcotte-Pugh Class A cirrhosis and a very low Model for End-Stage Liver Disease (MELD) score. Indications for liver transplantation are a MELD score of at least 15 or decompensated cirrhosis. Virologic cure in patients with compensated cirrhosis prevents decompensation. However, development of hepatocellular carcinoma would be a reason for referral for liver transplantation evaluation.
Measuring HCV RNA again in 12 weeks is not indicated because this patient has achieved virologic cure with undetectable HCV RNA at week 12 after completing treatment for HCV infection. Large studies have demonstrated 98% to 99% concordance between sustained virologic response at 12 and at 24 weeks. Therefore, sustained virologic response at 12 weeks is considered to be consistent with virologic cure, and additional testing is unnecessary.
Upper endoscopy is not necessary because the patient had an upper endoscopy 1 year ago. The standard follow-up interval for small varices in a patient who is not taking a nonselective β-blocker is 2 years.
- Patients with hepatitis C viral infection who achieve sustained virologic response have a reduced risk for hepatocellular carcinoma; regardless of virologic response, ultrasonographic surveillance is recommended for patients with stage 3 or stage 4 fibrosis.