In a 26‑year‑old patient who cleared hepatitis C one year ago with Epclusa (sofosbuvir/velpatasvir), should I obtain a routine liver ultrasound (annually or every 3 months), perform a fibrosis assessment, or schedule an upper endoscopy?

Post-SVR Surveillance in a Young Patient with Cleared HCV

In a 26-year-old patient who achieved sustained virologic response (SVR) one year ago, you need to perform non-invasive fibrosis testing now to determine if any ongoing surveillance is required—most patients without advanced fibrosis can be discharged from specialized care entirely.

Initial Assessment Required

The critical first step is determining the degree of liver fibrosis this patient had before or shortly after treatment. According to the 2024 EASL guidelines, your surveillance strategy depends entirely on fibrosis stage 1.

Perform Non-Invasive Fibrosis Testing Now

You should obtain:

• FIB-4 score (calculated from age, AST, ALT, platelet count—readily available)
• Liver stiffness measurement by transient elastography (VCTE-LSM/FibroScan) if available
• One-time abdominal ultrasound to assess for cirrhosis signs (nodular surface, splenomegaly, portal vein changes) 1

Using two non-invasive tests together improves accuracy for fibrosis staging 1. If there's discrepancy between methods, add a third test or ultrasound by an experienced operator 1.

Risk Stratification and Follow-Up Algorithm

If Minimal Fibrosis (VCTE-LSM <8 kPa OR FIB-4 <1.45):

Discharge from specialized hepatology care 1

• Follow-up with primary care physician only
• No routine liver ultrasounds needed
• No routine fibrosis testing needed
• No endoscopy needed
• Counsel on healthy lifestyle, avoid alcohol, maintain healthy weight
• The HCV infection is considered definitively cured with extremely low HCC risk 1

If Intermediate Fibrosis (VCTE-LSM 8-10 kPa AND/OR FIB-4 1.45-3.25):

This depends on comorbidities:

Without metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol intake <20g/day (women) or <30g/day (men):

• Can be discharged to primary care 1
• Repeat non-invasive testing in 1 year
• If improves to <8 kPa or FIB-4 <1.45, discharge completely

With MASLD (steatosis plus ≥1 cardiometabolic risk factor) OR harmful alcohol intake:

• Continue specialized hepatology follow-up 1
• Yearly assessment with non-invasive fibrosis tests 1
• No routine ultrasound for HCC screening needed
• No endoscopy needed

If Advanced Fibrosis/Cirrhosis (VCTE-LSM ≥10 kPa OR FIB-4 >3.25):

Continue specialized hepatology care indefinitely 1

• Laboratory testing every 6-12 months (platelets, bilirubin, albumin) 1
• Liver ultrasound every 6 months for HCC screening 1, 2
• Endoscopy decisions based on post-SVR VCTE-LSM and platelet count:
  • No EGD needed if VCTE-LSM <12 kPa AND platelets >150 G/L 1
  • No EGD needed if VCTE-LSM <20 kPa AND platelets >150 G/L (rules out high-risk varices) 1
  • EGD recommended if VCTE-LSM >20 kPa OR platelets <150 G/L 1

Critical Pitfalls to Avoid

1. Don't use pre-treatment fibrosis cut-offs post-SVR: Liver stiffness decreases after viral clearance due to reduced inflammation, so the diagnostic thresholds are different 1

2. Don't assume all post-SVR patients need ongoing surveillance: The 2024 EASL guidelines explicitly state patients with mild fibrosis achieving SVR have "no risk of clinical decompensation and an extremely low risk of HCC" 1

3. Age matters for risk: At 26 years old, this patient likely had a shorter duration of infection and lower likelihood of advanced fibrosis compared to older cohorts in most studies 2

4. Assess for cofactors: Diabetes, ongoing alcohol use, obesity, and MASLD increase progression risk even after SVR 1

Addressing Your Specific Questions

• Annual liver ultrasound? Only if advanced fibrosis/cirrhosis (VCTE-LSM ≥10 kPa or FIB-4 >3.25), then every 6 months 1
• Every 3 months ultrasound? Never indicated—too frequent even for cirrhosis
• Fibrosis test? Yes, perform now to stratify risk, then frequency depends on results as outlined above
• EGD? Only if advanced fibrosis/cirrhosis AND high-risk features (VCTE-LSM >20 kPa or platelets <150) 1

The Bottom Line

Most likely scenario: Given this patient's young age (26 years) and successful treatment one year ago, they probably have minimal to no fibrosis. Obtain FIB-4 and ideally VCTE-LSM now with one baseline ultrasound. If these show VCTE-LSM <8 kPa or FIB-4 <1.45 without concerning ultrasound findings, you can confidently discharge them from specialized hepatology care with no routine surveillance needed 1. The 2024 EASL guidelines are clear that patients without advanced fibrosis who achieve SVR can be considered definitively cured with extremely low complication risk.