John had attended the Medical Centre periodically for many years, usually when he had a problem that caused him pain or inconvenience. On this occasion, he had been called back because of some blood test results and John was quite rightly worried. He had a very swollen abdomen and this had coincided with some weight loss (in the order of ten kg over a month or so). John knew he had longstanding Hepatitis C and over a decade ago had seen a liver specialist. Apart from this, John had been reluctant to follow-up. Unfortunately, he had persisted in smoking and drinking over the years and still enjoyed doing both to excess.
John’s liver function tests were not much worse than when they were last done three years previously. However, his alpha-fetoprotein level was in the hundreds. Physical examination confirmed ascites, the stigmata of chronic liver disease (spider naevi, wasting of muscles, gynaecomastia, palmar erythema but in this case, no jaundice or liver flap). There was also a likely hepatocellular carcinoma; the liver was hard and took up the entire right upper quadrant of the abdomen, however, there were no bruits heard over the region. John was sent to hospital for a more detailed assessment and for probable arrangement of palliative care.
Regular screening is required for patients with Hepatitis C infection and cirrhosis, and for those who have chronic Hepatitis B infection, even if they do not have cirrhosis.1 Patients with chronic hepatitis C infection who have no cirrhosis do not require screening.1 Routine creening should be performed every six to twelve months and includes an ultrasound of the liver (for early identification of hepatocellular carcinoma) and an alpha fetoprotein level. Annual liver function tests, an INR and full blood tests are also advised. CT scanning is more accurate than ultrasound, (which is operator dependent and less accurate in obese individuals or in the presence of nodular liver). CT scanning, however, results in a higher false positive rate and involves radiation (and so is not ideal for routine screening).
It is particularly important that patients who are at increased risk of hepatocellular carcinoma should all be offered six-monthly screening. Those at high risk of this neoplasm include males, those with cirrhosis, those who have a family history of hepatocellular carcinoma, who are aged over forty years, patients who have co-infection with Hepatitis B, C or HIV, who have diabetes or who are overweight, drink excessive amounts of alcohol and those who have active viraemia or who have had a poor response to antiviral therapy.
Finally, patients with chronic liver disease of any cause who are not immune to Hepatitis A or B should be vaccinated for these diseases and tested for HIV.
1. El-Serag, H., Davila, J. Surveillance for hepatocellular carcinoma: in whom and how. Therap Adv Gastroenterol. 2011 Jan; 4(1): 5–10.