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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 58-year-old man undergoes follow-up evaluation for long-standing hyperlipidemia and gastroesophageal reflux disease (GERD). Both conditions are well controlled with medication. An upper endoscopy was performed 6 years ago at the time of his GERD diagnosis because of associated weight loss, and results were normal. A screening colonoscopy performed at the same time revealed three small hyperplastic polyps in the sigmoid colon. The patient's father died at age 60 years from alcohol-induced cirrhosis complicated by metastatic hepatocellular carcinoma. Family history is negative for primary relatives with colorectal cancer. Medications are simvastatin and esomeprazole. He does not use tobacco, alcohol, or injection drugs.

On physical examination, vital signs are normal; BMI is 28. The remainder of the physical examination is unremarkable.

Laboratory studies:

Albumin

4 g/dL (40 g/L)

Alkaline phosphatase

76 units/L

Alanine aminotransferase

33 units/L

Aspartate aminotransferase

20 units/L

Total bilirubin

1 mg/dL (17.1 μmol/L)

Total cholesterol

179 mg/dL (4.6 mmol/L)

Triglycerides

175 mg/dL (2.0 mmol/L)

Q.

For which of the following conditions should this patient undergo screening at this time?

This patient should undergo hepatitis C antibody testing to screen for chronic hepatitis C virus (HCV) infection. Previous recommendations suggested screening for HCV in patients who were considered to be at high risk (any history of injection drug use, blood transfusions before 1992, long-term use of hemodialysis, persistently elevated alanine aminotransferase levels). However, in 2012, the Centers for Disease Control and Prevention (CDC) updated recommendations to include one-time screening of all patients born between 1945 and 1965 without previous ascertainment of HCV risk. A draft recommendation statement from the United States Preventative Services Task Force (USPSTF) in 2012 similarly recommended that clinicians consider offering screening for HCV to all patients born between 1945 and 1965. According to the CDC, there are 2.7 to 3.9 million people living with HCV infection in the United States. All patients exposed to HCV develop a hepatitis C antibody and approximately 75% develop chronic infection. About two thirds of patients with HCV infection were born between 1945 and 1964. Chronic hepatitis C infection is the leading indication for liver transplantation among adults in the United States and is a major cause of hepatocellular carcinoma. Thus, early identification of infection, coupled with advances in effective therapy for hepatitis C, should lead to decreased transmission and improved outcomes.

Repeat upper endoscopy in patients with controlled gastroesophageal reflux disease to screen for Barrett esophagus is not indicated in patients who have a previously negative study and no change in their clinical status.

Based on this patient's previous screening colonoscopy, which demonstrated two small hyperplastic polyps in the sigmoid colon, in addition to a negative family history for colorectal cancer, a surveillance colonoscopy is indicated 10 years from his screening examination.

Screening for hepatocellular carcinoma is recommended in patients with cirrhosis. There is no reason to suspect underlying cirrhosis in this patient at the current time. There are no recommendations to screen for hepatocellular carcinoma based on family history alone.

There are no recommendations to support screening for nonalcoholic fatty liver disease, particularly in the setting of normal liver chemistry studies.

Key Point

  • In 2012, the Centers for Disease Control and Prevention updated hepatitis C virus (HCV) screening recommendations to include one-time screening of all patients born between 1945 and 1965 without previous ascertainment of HCV risk.
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