Q&A Medicine>>>>>Gastroenterology
Question 4#

A 49-year-old man with an extensive history of intravenous drug abuse over 10 years ago presents with anorexia, nausea, and malaise. He also reports dark urine for the last 2 months. His past medical history is significant for bipolar type 2 disorder. He takes no medications and reports a distant history of alcohol abuse. Physical examination is significant for hepatomegaly but no ascites. The patient demonstrates no signs of depression. Laboratory results reveal the following.

A biopsy of the liver is performed that demonstrates bridging fibrosis.

Which of the following is the best next step in management of this patient?

a. Follow-up in 4 months with monitoring of symptoms
b. Vaccinate him against hepatitis B virus (HBV) and Hepatitis A virus (HAV)
c. Upper endoscopy
d. Liver transplantation

Correct Answer is B

Comment:

Vaccinate him against hepatitis B virus (HBV) and Hepatitis A virus (HAV). The patient in this question has chronic hepatitis C virus (HCV) infection. Deciding to treat HCV depends on a variety of factors. Criteria for treatment that is considered “widely accepted” include patient age >18 years, liver biopsy demonstrating chronic hepatitis with bridging fibrosis, detectable serum HCV RNA, compensated liver disease (INR <1.5 without ascites), and stable laboratory findings such as creatinine and hemoglobin. Of note, contraindications to treatment include active and ongoing alcohol or drug abuse and uncontrolled depression, neither of which our patient demonstrates. Therefore, the decision to treat here is the best next step. Although the current gold standard HCV treatment is combination therapy with interferon and ribavirin, this is currently changing as research progresses to find more interferon-free regimens. However, regardless of the aforementioned criteria, the patient must be vaccinated against HBV and HAV. (A) Close observation is not the best step here as our patient meets all the criteria for treatment. (C) Upper endoscopy would be useful in a patient with cirrhosis who shows signs of portal hypertension (which our patient does not demonstrate). (D) Liver transplantation should only be considered in decompensated liver failure; however, our patient demonstrates normal INR and normal serum albumin levels.