What are the guidelines for abdominal ultrasound in hepatitis C (HCV) infection?

From the Guidelines

For patients with hepatitis C viral load, an abdominal ultrasound is recommended as part of the initial evaluation to assess for liver cirrhosis and hepatocellular carcinoma (HCC), with regular surveillance ultrasounds performed every 6 months in patients with evidence of cirrhosis. This recommendation is based on the increased risk of HCC in patients with chronic hepatitis C, particularly those with advanced fibrosis or cirrhosis, as highlighted in a study published in the Journal of Hepatology in 2023 1. The ultrasound evaluation should include assessment of liver parenchyma, nodularity, spleen size, and presence of ascites or portal hypertension. If concerning lesions are identified, further imaging with contrast-enhanced CT or MRI may be warranted.

Some key points to consider when performing abdominal ultrasounds for HCC surveillance in patients with hepatitis C include:

• The importance of high-quality equipment and special training for those performing ultrasounds for HCC surveillance, as emphasized in a study published in Gastroenterology in 2019 1
• The potential limitations of ultrasound in patients with cirrhosis, including operator dependency and the challenge of detecting HCC in a nodular cirrhotic liver
• The consideration of additional imaging techniques, such as CT or contrast-enhanced MRI, when ultrasound evaluation is technically challenging
• The optional use of serum alpha-fetoprotein (AFP) determination in addition to ultrasound, as recommended in the EASL guidelines 1

Overall, the goal of HCC surveillance is to detect HCC at early stages when curative therapies or liver transplantation can be considered, and regular ultrasound surveillance is a crucial component of this approach. As noted in a study published in Annals of Oncology in 2018, surveillance of patients at risk for HCC should be carried out by abdominal US every 6 months with or without AFP 1.

From the Research

Guidelines for Abdominal Ultrasound in HCV Infection

• The guidelines recommend surveillance of hepatocellular carcinoma (HCC) with abdominal ultrasound (US) for patients with advanced liver fibrosis due to hepatitis C virus (HCV) infections who achieve a sustained virological response (SVR) to antiviral therapy 2.
• Abdominal ultrasonography (with or without alpha fetoprotein) every six months is recommended for posttreatment surveillance for hepatocellular carcinoma and esophageal varices in patients with compensated cirrhosis 3.
• Current guidelines issued by AASLD and EASL recommend surveillance among high-risk patients by ultrasound (with or without alpha-fetoprotein) every 6 months 4.
• Surveillance with abdominal ultrasound with or without alpha-fetoprotein is recommended by clinical practice guidelines for patients who are considered to be at risk of developing hepatocellular carcinoma (HCC), including those with cirrhosis, advanced fibrosis and special subgroups of chronic hepatitis B (CHB) 5.

Patient Selection for Abdominal Ultrasound

• Patients at high risk for developing HCC should be included in surveillance programs, including all cirrhotic patients; non-cirrhotic patients with chronic hepatitis C and advanced liver fibrosis (F3) 4.
• Any person with ongoing risk factors should be screened periodically as long as the at-risk behavior persists, and one-time screening is recommended for patients younger than 18 years with risk factors 3.

Ultrasound Examination

• For good results, ultrasound examination must be done by highly experienced personnel, with extensive experience in the field of hepatic ultrasound 4.
• Shear wave elastography (SWE) is effective for the non-invasive assessment of liver fibrosis in patients with HCV infection, and provides a more accurate correlation with liver fibrosis stage than colour Doppler velocity profile for the assessment of liver fibrosis, especially in advanced stages (F3 and F4) 6.