What is the workup for a patient with Covid-19 (Coronavirus disease 2019) showing early signs of cirrhosis on a computed tomography (CT) scan of the abdomen?

Workup for Early Signs of Cirrhosis in a COVID-19 Patient

A comprehensive hepatology workup is essential for a COVID-19 patient with early signs of cirrhosis on abdominal CT scan, focusing on identifying the underlying etiology and assessing disease severity to guide management decisions. 1

Initial Laboratory Evaluation

• Complete liver function panel:

  • ALT, AST (abnormal in 15% of COVID-19 patients) 1
  • Alkaline phosphatase
  • Total and direct bilirubin
  • Albumin (hypoalbuminemia reflects COVID-19 severity) 1
  • Prothrombin time/INR

• Viral hepatitis screening:

  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis C antibody (anti-HCV) 1

• Autoimmune markers:

  • Antinuclear antibody (ANA)
  • Anti-smooth muscle antibody (ASMA)
  • Anti-mitochondrial antibody (AMA)
  • Immunoglobulin levels (IgG, IgA, IgM)

• Metabolic workup:

  • Ferritin, iron, TIBC (hemochromatosis)
  • Ceruloplasmin (Wilson's disease)
  • Alpha-1 antitrypsin level
  • Lipid profile and HbA1c (NAFLD/NASH)

Imaging Studies

• Bedside ultrasonography: First-line imaging to evaluate for:

  • Liver nodularity and surface irregularity
  • Portal hypertension (splenomegaly, portal vein diameter)
  • Ascites
  • Hepatocellular carcinoma screening
  • Biliary pathology 1

• Defer routine FibroScan during acute COVID-19 infection 1

• Reserve additional imaging (MRI/MR elastography) for after COVID-19 recovery unless emergent conditions are suspected

Assessment of Cirrhosis Severity

• Calculate MELD and Child-Pugh scores to assess severity and prognosis
• Screen for complications:
  • Esophageal varices (plan endoscopy after COVID-19 recovery)
  • Ascites
  • Hepatic encephalopathy
  • Hepatorenal syndrome

Special Considerations for COVID-19 Patients

• Monitor for COVID-19 related liver injury:

  • COVID-19 can cause liver enzyme elevations in up to 54% of patients 2
  • Patients with cirrhosis have higher mortality rates when infected with COVID-19 (30-day mortality of 34%) 3

• Evaluate for drug-induced liver injury:

  • Review all medications including COVID-19 treatments
  • Follow US Drug-Induced Liver Injury Expert Working Group recommendations 1
  • Consider stopping hepatotoxic drugs if ALT >5× ULN or ALP >2× ULN with bilirubin >2× ULN 1

• Assess for COVID-19 complications that may affect the liver:

  • Myositis (especially when AST exceeds ALT)
  • Ischemia
  • Cytokine release syndrome 1

Management Approach

1. Determine underlying etiology of cirrhosis to guide specific treatment
2. Manage COVID-19 according to current guidelines
3. Monitor liver function tests regularly during COVID-19 treatment regardless of baseline results 1
4. Defer non-urgent procedures until COVID-19 resolution
5. Consider early hepatology consultation for management guidance

Pitfalls to Avoid

• Don't assume liver dysfunction is solely due to COVID-19 - complete evaluation for underlying chronic liver disease is essential
• Avoid unnecessary transport for non-urgent imaging during active COVID-19 infection 1
• Don't mistake COVID-19 related liver injury for a flare of autoimmune hepatitis without biopsy confirmation 1
• Don't discontinue COVID-19 treatments prematurely - abnormal liver function tests alone are not a contraindication for experimental COVID-19 treatments 1

By following this systematic approach, you can properly evaluate and manage a patient with COVID-19 showing early signs of cirrhosis on CT scan, potentially improving both short and long-term outcomes.