A 54-year-old man comes to the office due to a recent finding of abnormal liver function tests. Four weeks ago, he went to the emergency department due to 2 days of diarrhea and vomiting. During the evaluation for viral gastroenteritis, the patient was found to have elevated liver aminotransferase levels and was advised to follow up with his primary care physician. Since then, his gastrointestinal symptoms have improved. He has had no fever, abdominal pain, nausea, vomiting, jaundice, or pruritus. The patient has no chronic medical problems. He had an appendectomy during childhood with some operative complications requiring blood transfusions. His only medication is ibuprofen as needed. The patient does not use tobacco or illicit drugs and drinks alcohol occasionally. He is married and in a monogamous relationship. Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 78/min. He has no scleral icterus, and mucous membranes are pink and moist. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender with no organomegaly. Current laboratory results are as follows: The laboratory results are discussed with the patient, and a plan for treatment with direct-acting antivirals is made. The patient agrees to abstinence from alcohol as well as regular follow-up. Which of the following additional interventions is most appropriate in this patient?

Question

A 54-year-old man comes to the office due to a recent finding of abnormal liver function tests.  Four weeks ago, he went to the emergency department due to 2 days of diarrhea and vomiting.  During the evaluation for viral gastroenteritis, the patient was found to have elevated liver aminotransferase levels and was advised to follow up with his primary care physician.  Since then, his gastrointestinal symptoms have improved.  He has had no fever, abdominal pain, nausea, vomiting, jaundice, or pruritus.  The patient has no chronic medical problems.  He had an appendectomy during childhood with some operative complications requiring blood transfusions.  His only medication is ibuprofen as needed.  The patient does not use tobacco or illicit drugs and drinks alcohol occasionally.  He is married and in a monogamous relationship.  Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 78/min.  He has no scleral icterus, and mucous membranes are pink and moist.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and nontender with no organomegaly.  Current laboratory results are as follows:  The laboratory results are discussed with the patient, and a plan for treatment with direct-acting antivirals is made.  The patient agrees to abstinence from alcohol as well as regular follow-up.  Which of the following additional interventions is most appropriate in this patient?

Quizplus · Accepted Answer

Explanation: This patient with elevated liver function test results has positive hepatitis C virus (HCV) antibodies and circulating HCV RNA, consistent with chronic HCV infection. Chronic HCV infection is frequently asymptomatic, and many patients have only minimal laboratory abnormalities. The mainstay of treatment is direct-acting antiviral agents (eg, sofosbuvir-velpatasvir), which have dramatically improved the ability to achieve virologic cure, but patients also require additional strategies to prevent further liver damage. A primary concern is a superimposed infection with hepatitis A virus (HAV) or hepatitis B virus (HBV), which dramatically increases the risk for rapid hepatic decompensation and liver failure. As such, patients with chronic HCV require vaccination against HAV and HBV if they do not have preexisting immunity. This patient is not immune to HAV (negative HAV antibody) and should receive HAV vaccination. He does have evidence of immunity to HBV (positive HBV surface antibody) with no suggestion of active HBV infection (negative HBV surface antigen); therefore, he does not require additional laboratory testing for HBV or vaccination against HBV (Choice E). Patients with chronic HCV infection should also receive screening for complications and comorbidities, including liver fibrosis, renal disease, and extrahepatic manifestations (eg, cryoglobulinemia). All patients should receive counseling on substance abuse and alcohol cessation. (Choice A) HCV is primarily acquired through parenteral exposure to blood with intravenous drug use or through HCV-contaminated blood transfusion. Unlike HBV or HIV, sexual contact is a rarer form of transmission; consequently, barrier protection is usually not recommended. (Choice B) Although many patients with chronic HCV infection are concerned about the use of acetaminophen, patients can generally safely take <2 g a day without adverse consequences.(Choice C) Chronic HCV infection historically was treated with interferon and ribavirin, and drug-associated depression was common. However, depression side effects are less prominent with direct-acting antiviral agents, and consequently, routine depression screening is no longer required. Educational objective: Patients with chronic hepatitis C infection may experience rapid hepatic decompensation and liver failure if they develop acute hepatitis A virus (HAV) or hepatitis B virus (HBV) infection. Consequently, in addition to alcohol avoidance, patients should be vaccinated against HAV and HBV if they do not have preexisting immunity. References: Hepatitis C: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20521755)

A 54-Year-Old Man Comes to the Office Due to a Recent