What is the recommended screening for the right upper quadrant in patients with hepatitis?

Screening Right Upper Quadrant in Hepatitis

All patients with chronic hepatitis B or C should undergo right upper quadrant ultrasound every 6 months for hepatocellular carcinoma (HCC) surveillance if they are at high risk, which includes those with cirrhosis, men over 40 years, women over 50 years, or those with a family history of HCC. 1

Who Requires HCC Screening

Hepatitis B Patients at High Risk:

• Asian men over 40 years and Asian women over 50 years 1
• All patients with cirrhosis regardless of age 1
• Patients with a family history of HCC 1
• Africans over 20 years of age 1
• Any carrier over 40 years with persistent or intermittent ALT elevation and/or high HBV DNA level >2,000 IU/mL 1

Hepatitis C Patients at High Risk:

• All patients with known or suspected cirrhosis 1
• Patients with advanced fibrosis 1

Screening Protocol

The standard screening approach combines right upper quadrant ultrasound with serum alpha-fetoprotein (AFP) measurement every 6 months. 1

Ultrasound as Primary Tool:

• Ultrasound has higher sensitivity, specificity, and diagnostic accuracy than AFP alone 1
• Ultrasound should be performed every 6-12 months in high-risk patients 1
• For patients with severe cirrhosis or obesity where ultrasound has poor sensitivity, magnetic resonance imaging or computed tomography may be preferred 1

AFP Considerations:

• AFP should be used when ultrasound is not readily available or cost is an issue 1
• AFP has a specificity above 90% but low positive predictive value (9-30%) 1
• Rising AFP levels in a step-like manner strongly suggest HCC presence 1

Additional Right Upper Quadrant Assessment

Initial Evaluation:

Physical examination of the right upper quadrant should assess for:

• Liver size and consistency - inability to palpate the liver may indicate massive hepatocyte loss, while an enlarged liver may suggest acute viral hepatitis, malignant infiltration, congestive heart failure, or acute Budd-Chiari syndrome 1
• Right upper quadrant tenderness - variably present in acute liver failure 1
• Signs of portal hypertension or cirrhosis 1

Baseline Imaging:

All patients with newly diagnosed chronic hepatitis should obtain a baseline liver ultrasound as part of their initial evaluation 1, 2

Special Populations

NAFLD/NASH Patients:

Patients with nonalcoholic fatty liver disease who develop cirrhosis require right upper quadrant ultrasound every 6 months for HCC screening, following the same AASLD guidelines as viral hepatitis 1

Patients on Hemodialysis:

HCV-infected patients with end-stage renal disease scheduled for kidney transplantation should undergo antiviral therapy prior to transplantation, with appropriate HCC screening if cirrhotic 1

Critical Pitfalls to Avoid

• Do not rely solely on AFP for HCC screening - ultrasound is superior and should be the primary modality 1
• Do not delay screening until symptoms develop - HCC surveillance must be performed at regular 6-month intervals in high-risk patients 1
• Do not assume younger patients are at low risk - Asian patients with presumed perinatal infection may require earlier screening (at 30-35 years or younger) due to higher HCC risk 1
• Do not discontinue HCC surveillance after successful viral eradication in cirrhotic patients - screening must continue indefinitely in patients with cirrhosis 1