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Cirrhosis

NICE guideline [NG50] Cirrhosis in over 16s: assessment and management. Last updated: Sep 2023. BSC Guidelines on the Management of Ascites in Cirrhosis BSG Best Practice Guidance: outpatient management of cirrhosis - part 1: compensated cirrhosis BSG Best Practice Guidance: outpatient management of cirrhosis - part 2: decompensated cirrhosis

Guidelines

Transient elastrography (e.g. FibroScan) should be offered to the following to diagnose cirrhosis:
  • Hepatitis C virus infection
  • People who drink excess alcohol (men >50 units and women>35 units per week)
  • Alcohol-related liver disease
  • NAFLDNon-alcoholic fatty liver disease only if there is advanced liver fibrosis (defined by ELFEnhanced liver fibrosis score ≥10.51) - see this article for more information on NAFLD

 

For concept-based exam questions:

  • Ultrasound is usually the initial imaging modality in those with suspected liver disease, but it has limited sensitivity in diagnosing cirrhosis. So its role is limited to detecting the presence of liver disease, and guiding subsequent testing, but NOT diagnosing cirrhosis.
 
  • 1st line investigation (for cirrhosis): transient elastrography (e.g. FibroScan) - increased liver stiffness suggests cirrhosis
  • Definitive testing: liver biopsy (not routinely used, only if transient elastography is not feasible and still unclear)

Calculate MELD score every 6 months:
  • ≥12 indicates high risk of complications

The following complications should be monitored in those with cirrhosis:
 
Complication Test
Hepatocellular carcinoma Ultrasound +/- AFPAlpha-fetoprotein every 6 months
Oesophageal varices Perform upper GI endoscopy after diagnosis (unless planning to take carvedilol or propranolol)

For subsequent monitoring, see below.

No specific management, with the aim of preventing progression of liver disease and complications:
  • Complete alcohol abstinence
  • Weight loss (in overweight / obesity / NAFLD patients)
  • Routine vaccinations (for all chronic liver disease patients)
    • Annual influenza
    • Pneumococcal
    • Hepatitis A and B
    • SARS-CoV-2
  • Ensure adequate nutrition
  • Screening and monitoring for complications (see above)

Primary prevention of decompensation:
  • 1st line: carvedilol
  • 2nd line: propranolol

Screening upper GI endoscopy should be offered if not on NSBBNon-selective beta blocker (carvedilol or propranolol):
  • No varices → annual surveillance
  • Small varices → annual surveillance or primary prophylaxis with carvedilol (if Child Pugh class C)
  • Medium / large varices → primary prophylaxis
    • 1st line: NSBBNon-selective beta blocker (carvedilol / propranolol)
    • 2nd line: endoscopic variceal band ligation

No further surveillance needed if on NSBBNon-selective beta blocker for primary prophylaxis.

For management of other acute upper GI bleeds, see this article.

Pre-endoscopic management (in addition to resuscitation) for ALL patients:
  • Terlipressin (stop after 5 days or after definitive haemostasis), and
  • Prophylactic antibiotic

Endoscopic interventions:
  • Oesophageal varices → band ligation
  • Gastric varices → cyanoacrylate glue injection (chemical ligation)
 
  • If failed → TIPS
  

NICE does not recommend the routine use of the Sengstaken-Blakemore tube (a type of balloon tamponade), due to risk of complications like aspiration and oesophageal perforation.

However, it is still occasionally used in emergencies when endoscopic treatment fails or endoscopy is not immediately available in massive bleeding.

Offer all the following:
  • Carvedilol
  • Variceal band ligation every 4 weeks until eradication
  • Surveillance upper GI endoscopy

  • 1st line: lactulose
  • 2nd line: rifaximin

Phosphate enema can also be used.

 

Note that hepatic encephalopathy can develop after TIPSS (35-50%). This can be prevented by using a smaller diameter stent and the use of prophylactic rifaximin before TIPSS.

Weight loss and sarcopaenia can worsen hepatic encephalopathy, therefore low-protein nutrition should be avoided, and maintain adequate protein and energy intake.

All patients:
  • Dietary salt restriction (but no routine fluid restriction)
  • Stop exacerbating medications (e.g. NSAIDs, ACE inhibitors)
  • Spironolactone 
    • If inadequate or severe ascites: add furosemide to spironolactone

Other procedures:
  • Consider therapeutic large-volume paracentesis for tense or refractory ascites
    • Followed by IV albumin infusion to prevent paracentesis-induced circulatory dysfunction
  • Last resort: TIPSTransjugular intrahepatic portosystemic shunt

Empirical antibiotic therapy for SBP:

  • IV ceftriaxone, or
  • Oral co-amoxiclav (for outpatient management)

Do not routinely offer antibiotics to prevent SBP

Consider prophylactic antibiotic (ciprofloxacin / norfloxacin / co-trimoxazole) if:
  • Previous episode of SBP (secondary prevention), or
  • Severe liver disease (ascitic protein ≤15 / Child-Pugh score >9 / MELD score >16), or
  • Consequences of SBP could seriously impact the patient's care (e.g. affect their wait for TIPS)

High-yield BSG recommendations:
 
Symptom Recommendation
Pain
  • 1st line: paracetamol
  • If opioids are needed, 1st line is morphine if eGFR >30, hydromorphone if eGFR <30 (monitor for constipation and encephalopathy)

Avoid the following if possible:
  • NSAIDs (bleeding risk and nephrotoxic)
  • Tramadol (lowers seizure threshold)
  • Coedeine
Nausea and vomiting
  • 1st line:
    • GI causes: metoclopramide / domperidone
    • CNS causes / opioid induced: haloperidol
  • 2nd line:
    • Ondansetron
    • Levomepromazine
 

References

Author: Adams Lau
Reviewer:
Last edited: 10/08/25