What are the next steps after a new diagnosis of cirrhosis on Computed Tomography (CT) scan?

Management of Newly Diagnosed Cirrhosis on CT Scan

After a new diagnosis of cirrhosis on CT scan, the next steps should include a comprehensive hepatology evaluation, laboratory assessment, screening for hepatocellular carcinoma (HCC), and assessment for complications of portal hypertension. 1, 2

Initial Evaluation

Laboratory Assessment

• Complete liver function tests (AST, ALT, bilirubin, albumin)
• Coagulation profile (INR/PT)
• Complete blood count with platelets
• Renal function tests
• Etiological workup:
  • Viral hepatitis serologies (HBV, HCV)
  • Iron studies (ferritin, transferrin saturation)
  • Autoimmune markers if clinically indicated
  • Alpha-fetoprotein (AFP) for HCC screening 1, 2

Imaging Follow-up

• MRI with contrast is the preferred imaging modality for further characterization of liver lesions and assessment of cirrhosis severity 2
• If any nodules >1 cm are identified:
  • For nodules 1-2 cm: At least two dynamic studies (multiphasic CT, MRI with contrast, or contrast-enhanced ultrasound) 1
  • For nodules >2 cm with typical HCC features on dynamic imaging: Consider as HCC and plan appropriate treatment 1
  • For nodules <1 cm: Follow-up ultrasound at 3-4 month intervals in the first year 1

Staging and Risk Assessment

Severity Assessment

• Calculate Child-Pugh score and MELD score 3
• Assess for morphologic features of advanced cirrhosis:
  • Liver surface nodularity
  • Right lobe atrophy with caudate lobe hypertrophy
  • Expanded gallbladder fossa
  • Narrow hepatic veins 2

Non-invasive Fibrosis Assessment

• Consider transient elastography (FibroScan) or ARFI to confirm and stage cirrhosis 2
• Calculate non-invasive fibrosis scores:
  • APRI (AST-to-Platelet Ratio Index)
  • FIB-4 score 2, 4

Screening for Complications

Hepatocellular Carcinoma Surveillance

• Implement HCC surveillance with ultrasound every 6 months 1, 2
• Consider adding AFP measurement to ultrasound for surveillance 1, 2

Portal Hypertension Assessment

• Upper endoscopy to screen for esophageal and gastric varices 5
• If varices are present, consider prophylaxis with non-selective beta blockers 4

Other Complications Screening

• Assess for ascites with physical examination and imaging
• Screen for hepatic encephalopathy with clinical evaluation
• Evaluate for signs of hepatorenal syndrome 5

Management Considerations

Lifestyle Modifications

• Counsel regarding complete alcohol abstinence
• Weight management for patients with NAFLD/NASH
• Vaccination against hepatitis A and B if not immune
• Annual influenza vaccination 3, 4

Medication Review

• Avoid hepatotoxic medications
• Adjust dosages of medications metabolized by the liver
• Consider prophylactic antibiotics if high risk for spontaneous bacterial peritonitis 4, 5

Referral Considerations

• Refer to hepatologist for specialized care
• Consider liver transplant evaluation for:
  • MELD score ≥15
  • Complications of cirrhosis
  • Presence of HCC 3

Common Pitfalls to Avoid

1. Delaying HCC surveillance - Begin immediately after diagnosis of cirrhosis, as early detection significantly improves outcomes 1, 2

2. Inadequate follow-up of small nodules - Nodules <1 cm require close monitoring with ultrasound every 3-4 months initially 1

3. Overreliance on AFP alone - AFP has limited sensitivity (39-65%) for HCC detection and should be used in conjunction with imaging 2

4. Failure to assess for varices - All newly diagnosed cirrhotic patients should undergo endoscopic screening for varices 4, 5

5. Neglecting to identify and treat the underlying cause - Addressing the etiology of cirrhosis (viral hepatitis, alcohol, NAFLD) can potentially slow or reverse early cirrhosis 3, 4