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Zorluk: ZorPreventive Care and Screening

A 48-year-old woman comes to the clinic for a routine health maintenance visit. She was diagnosed with chronic hepatitis C virus (HCV) infection 6 years ago. At the time of diagnosis, transient elastography demonstrated a liver stiffness of 16 kPa16 \text{ kPa}, consistent with compensated cirrhosis. She was subsequently treated with a 12-week course of direct-acting antivirals and achieved a sustained virologic response (cure) 5 years ago. She has no history of ascites, hepatic encephalopathy, or variceal bleeding.

She feels well and has no current symptoms. She takes no medications and does not use alcohol, tobacco, or illicit drugs.

Vital signs are within normal limits. Physical examination reveals a palpable, firm liver edge but no splenomegaly, jaundice, or stigmata of chronic liver disease.

Recent laboratory studies show:
Laboratory TestResultReference Range
Platelet count175,000/mm3175,000/\text{mm}^3150,000−400,000/mm3150,000-400,000/\text{mm}^3
Total bilirubin0.9 mg/dL0.9 \text{ mg/dL}0.1−1.2 mg/dL0.1-1.2 \text{ mg/dL}
Alanine aminotransferase (ALT)22 U/L22 \text{ U/L}10−40 U/L10-40 \text{ U/L}
Aspartate aminotransferase (AST)24 U/L24 \text{ U/L}10−40 U/L10-40 \text{ U/L}
International normalized ratio (INR)1.11.10.8−1.10.8-1.1

Her most recent screening mammogram 6 months ago was normal. Her last colonoscopy at age 45 was normal.

Vaccination history includes a complete hepatitis A and B series, the 20-valent pneumococcal conjugate vaccine (PCV20) 2 years ago, Tdap 3 years ago, and the annual influenza vaccine.

Which of the following is the most appropriate next step in this patient's preventive management?

  1. Abdominal ultrasonographyCevap
  2. B
    Esophagogastroduodenoscopy
  3. C
    Hepatitis C virus antibody testing
  4. D
    Recombinant zoster vaccine
  5. E
    Fecal immunochemical testing

Cevap

Abdominal ultrasonography
The correct answer is abdominal ultrasonography. Patients with chronic hepatitis C virus (HCV) infection who develop cirrhosis remain at a significantly elevated risk for hepatocellular carcinoma (HCC), even after achieving a sustained virologic response (SVR, or virologic cure) with direct-acting antivirals. Therefore, current guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend lifelong HCC surveillance for all patients with cirrhosis, regardless of the etiology or viral cure status. The standard surveillance modality is abdominal ultrasonography every 6 months, with or without serum alpha-fetoprotein (AFP) testing.

Adım Adım Çözüm

1
Identify the patient's underlying chronic conditions and treatment history.
The patient has a history of chronic HCV that was successfully treated (SVR), but she developed compensated cirrhosis prior to treatment.
Preventive care guidelines in hepatology are heavily influenced by the presence of irreversible architectural liver damage (cirrhosis), regardless of the current viral status.
2
Determine the ongoing screening requirements for a patient with cirrhosis post-HCV cure.
Because liver fibrosis and cirrhosis persist despite viral cure, the risk of hepatocellular carcinoma (HCC) remains significantly elevated.
AASLD guidelines mandate lifelong HCC screening (using abdominal ultrasonography every 6 months) for any patient who has developed cirrhosis.
3
Evaluate the need for other cirrhosis-related screenings, such as for esophageal varices.
The patient has a platelet count > 150,000/mm³ and a liver stiffness < 20 kPa.
According to the Baveno criteria, patients meeting these specific thresholds are at a very low risk for clinically significant varices and can safely defer screening esophagogastroduodenoscopy (EGD).
4
Review age-based preventive care and vaccine history.
The patient is up to date on colon cancer screening, breast cancer screening, and all indicated vaccines.
Confirms that no other routine primary care interventions take precedence over HCC screening.

Anahtar Kavram

Patients with cirrhosis caused by hepatitis C virus who achieve a sustained virologic response (cure) remain at high risk for hepatocellular carcinoma and require lifelong surveillance with abdominal ultrasonography every 6 months.
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Preventive Care and Screening

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