What is the most appropriate next step for an elderly woman with a history of pruritus and fatigue, presenting with jaundice, abdominal swelling, splenomegaly, ascites, and a 3 cm focal liver lesion, with abnormal lab results including thrombocytopenia, anemia, leukopenia, coagulopathy, and elevated liver enzymes?

Triphasic CT Scan of the Abdomen

The most appropriate next step is a triphasic CT scan of the abdomen (Option D) to characterize the 3 cm focal liver lesion and assess for hepatocellular carcinoma in this patient with clear evidence of chronic liver disease and cirrhosis.

Clinical Context and Rationale

This elderly woman presents with a classic constellation of findings indicating advanced chronic liver disease with cirrhosis and portal hypertension:

• Long-standing pruritus and fatigue suggest chronic cholestatic liver disease, possibly primary biliary cholangitis 1
• Jaundice, ascites, and splenomegaly indicate decompensated cirrhosis with portal hypertension 2
• Laboratory findings demonstrate:
  • Pancytopenia (thrombocytopenia, anemia, leukopenia) consistent with hypersplenism and advanced liver disease 3, 4
  • Coagulopathy (INR 1.5) reflecting hepatic synthetic dysfunction 3
  • Cholestatic pattern (elevated alkaline phosphatase) with elevated transaminases 2
• Coarse liver on ultrasound confirms cirrhosis 2

Why Triphasic CT is the Correct Next Step

In a cirrhotic patient with a focal liver lesion ≥1 cm, triphasic (dynamic contrast-enhanced) CT is the appropriate diagnostic imaging modality to characterize the lesion and evaluate for hepatocellular carcinoma (HCC). 2

Key Advantages of Triphasic CT:

• Characterizes vascular enhancement patterns that distinguish HCC from other lesions through arterial, portal venous, and delayed phases 5
• Provides comprehensive abdominal assessment including evaluation of portal hypertension, ascites, and other complications 2
• High diagnostic accuracy for HCC in cirrhotic patients when characteristic enhancement patterns are present 2
• Guides further management including potential biopsy, treatment planning, or surveillance 2

Why Other Options Are Inappropriate

Alpha-fetoprotein (Option A):

• Not a diagnostic test for focal liver lesions; lacks sensitivity and specificity for HCC
• Should be obtained but cannot replace imaging characterization of the lesion
• Does not provide information about lesion characteristics, extent of disease, or complications

Biopsy for the Lesion (Option B):

• Premature without imaging characterization first 2
• Carries increased bleeding risk given thrombocytopenia (102 × 10⁹/L) and coagulopathy (INR 1.5) 3
• Triphasic CT may provide definitive diagnosis without biopsy if characteristic HCC features are present
• Biopsy reserved for lesions with indeterminate imaging findings 2

Doppler Ultrasound of Liver (Option C):

• Insufficient for lesion characterization in this clinical context
• Primarily evaluates vascular patency (portal vein thrombosis, hepatic vein thrombosis)
• Does not provide the dynamic enhancement patterns necessary to characterize focal liver lesions 2
• Already have ultrasound showing the lesion; need more sophisticated imaging

Clinical Pitfalls to Avoid

• Do not delay imaging characterization in cirrhotic patients with focal lesions, as early HCC detection significantly impacts treatment options and prognosis 2
• Do not proceed directly to biopsy without cross-sectional imaging, especially with coagulopathy present 2
• Recognize that this patient has decompensated cirrhosis requiring hepatology referral for comprehensive management including HCC screening protocols 2

Subsequent Management Algorithm

After triphasic CT:

• If characteristic HCC features (arterial hyperenhancement with portal/delayed washout): Proceed to multidisciplinary tumor board discussion for treatment planning
• If indeterminate findings: Consider MRI with contrast or biopsy 2
• Refer to hepatology for cirrhosis management, portal hypertension treatment, and potential liver transplant evaluation 2
• Initiate HCC surveillance protocol if not already established 2

The presence of cirrhosis, portal hypertension, and a focal liver lesion creates high suspicion for HCC, making definitive lesion characterization the immediate priority before any invasive procedures 2.