Choose Your Tests Wisely: Advice From the AASLD

Lauri R. Graham; Raphael B. Merriman, MD, FRCPI


November 10, 2014

Medscape: Your second recommendation is: Don't continue treatment for hepatic encephalopathy indefinitely after an initial episode with an identifiable precipitant.

Dr Merriman: This reflects a recommendation made in the recently published practice guideline on hepatic encephalopathy, which was jointly developed by the AASLD with the European Association for the Study of the Liver.

Patients may have episodes of hepatic encephalopathy with precipitating factors that can be identified and controlled, such as recurrent infections or variceal hemorrhage. In those circumstances where the precipitating factors are clearly identified and well controlled, the treatment of hepatic encephalopathy may not necessarily be indefinite and indeed could be discontinued.

This is important because in the past, it has been common practice to continue the prophylactic treatment of hepatic encephalopathy indefinitely after it was initiated, even though there was little basis to actually support that. So this recommendation has significant implications to reduce unnecessary use of therapeutics to prevent recurrent hepatic encephalopathy.

Medscape: Your third recommendation is: Don't repeat hepatitis C viral load testing outside of antiviral therapy.

Dr Merriman: This is an important, topical, and relevant recommendation, particularly in the context of the transformative changes occurring in the field of hepatitis C therapeutics with the imminent availability of a whole host of new, highly effective hepatitis C antiviral agents that are curing hepatitis C.

Highly sensitive serum assays of hepatitis C RNA are expensive. Performing these assays is appropriate at the time of diagnosis of hepatitis C and as part of antiviral therapy, typically at the beginning of and possibly during therapy, and also after therapy is completed. Outside of these circumstances, there is little benefit to measuring the hepatitis C viral RNA load, as it typically does not affect either the clinical management or outcomes.

This recommendation is of particular relevance to patients because, oftentimes, there is a mistaken patient perception that the testing is needed, that there is significance to quite modest changes in the hepatitis C viral load, and that it actually affects clinical outcomes. Therefore, this recommendation will prompt a discussion that should hopefully reduce the need for unnecessary virologic testing.

Medscape: Your fourth recommendation is: Don't perform CT or MRI routinely to monitor benign focal lesions in the liver unless there is a major change in clinical findings or symptoms.

Dr Merriman: Many patients have focal liver lesions detected by imaging—often incidentally—who don't have underlying liver disease and that are determined to be benign. Those who demonstrate both clinical and radiologic stability do not need repeated imaging as the likelihood of evolving into neoplastic lesions is very low (with the exception of hepatocellular adenoma). Clinical stability implies the absence of any new symptoms related to these focal liver lesions. This recommendation stems from a common perception that even after clinical and radiologic stability of the benign focal lesions has been demonstrated, that imaging needs to be repeated indefinitely. This recommendation provides guidance to support discontinuing serial imaging in these patients.

Because these lesions are often found incidentally and frequently in younger people, the additional implication of this recommendation is that we can reduce and avoid both unnecessary imaging and, in the case of CT scanning, unnecessary radiation exposure in this patient population.

Medscape: You mentioned the exception to this recommendation being hepatocellular adenoma.

Dr Merriman: Yes; this recommendation does not apply to those with hepatocellular adenoma. Patients with radiologic evidence of hepatocellular adenoma may have a risk of the lesion potentially transforming into a more neoplastic variant. These patients are typically monitored more closely, often depending in part upon the size of the lesion. However, it is important to remember that this represents a very small proportion of the total number of benign focal liver lesions.


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