What is the recommended screening protocol for patients with hepatitis C, specifically for right upper quadrant (RUQ) monitoring?

Right Upper Quadrant Screening in Hepatitis C Patients

Patients with hepatitis C and compensated cirrhosis require ultrasound of the liver conducted within the prior 6 months as part of pretreatment assessment to exclude hepatocellular carcinoma (HCC) and subclinical ascites. 1

Screening Protocol Based on Cirrhosis Status

Patients WITH Cirrhosis (Compensated)

Pretreatment ultrasound screening is mandatory:

• Liver ultrasound must be performed within 6 months prior to initiating HCV treatment 1
• The primary purpose is to exclude HCC and detect subclinical ascites 1
• This applies to all treatment-naive patients with compensated cirrhosis (Child-Pugh A) 1

Ongoing HCC surveillance after achieving cure:

• Patients with cirrhosis require lifelong HCC surveillance even after sustained virologic response (SVR) 1, 2
• Ultrasound examination of the liver every 6 months is the recommended screening modality 1
• Combined use of ultrasound with alpha-fetoprotein (AFP) increases sensitivity while decreasing specificity and represents a reasonable option 1
• This surveillance should continue indefinitely as cirrhosis persists despite viral cure 1, 2

Patients WITHOUT Cirrhosis

No routine ultrasound screening is required:

• The AASLD/IDSA guidelines do not mandate pretreatment ultrasound for non-cirrhotic patients 1
• Cirrhosis assessment is performed using FIB-4 score and other noninvasive methods rather than imaging 1
• After achieving SVR in the absence of cirrhosis, no liver-related imaging follow-up is recommended 2

Determining Cirrhosis Status

Multiple noninvasive methods can identify cirrhosis without requiring ultrasound initially:

• FIB-4 score >3.25 suggests cirrhosis 1
• Transient elastography (FibroScan) stiffness >12.5 kPa indicates cirrhosis 1
• Clinical evidence including liver nodularity and/or splenomegaly on imaging, or platelet count <150,000/mm³ 1
• Noninvasive serologic tests above proprietary cutoffs (FibroSure, Enhanced Liver Fibrosis Test) 1

Critical Pitfalls to Avoid

Do not skip pretreatment ultrasound in cirrhotic patients:

• Known or suspected HCC is an absolute contraindication to simplified treatment protocols 1
• Detecting HCC before treatment initiation fundamentally changes management 1
• Subclinical ascites may indicate more advanced disease than clinically apparent 1

Do not discontinue HCC surveillance after viral cure:

• The risk of HCC persists in patients with cirrhosis even after achieving SVR 1, 2
• Screening must continue every 6 months indefinitely 1
• This is a common error as patients and providers may assume cure eliminates all risk 2

Post-Treatment Monitoring

For patients with cirrhosis who achieve SVR:

• Abdominal ultrasonography (with or without AFP) every 6 months for HCC surveillance 2
• Upper endoscopy every 2-3 years for esophageal varices screening 2
• Assessment for disease progression every 6-12 months with hepatic function panel, CBC, and INR if unable to be retreated 1

For patients without cirrhosis who achieve SVR:

• No routine liver-related imaging follow-up is necessary 2
• Assessment for other causes of liver disease only if transaminases remain elevated 1