Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Diagnosis

1.1.1 Be aware that there is an increased risk of cirrhosis in people who:

1.1.2 Discuss with the person the accuracy, limitations and risks of the different tests for diagnosing cirrhosis. [2016]

1.1.3 Offer transient elastography to diagnose cirrhosis for:

  • people with hepatitis C virus infection

  • men and people registered male at birth who drink over 50 units of alcohol per week and have done so for several months

  • women and people registered female at birth who drink over 35 units of alcohol per week and have done so for several months

  • people diagnosed with alcohol-related liver disease. [2016]

1.1.4 Offer either transient elastography or acoustic radiation force impulse imaging (whichever is available) to diagnose cirrhosis for people with NAFLD and advanced liver fibrosis (as diagnosed by a score of 10.51 or above using the enhanced liver fibrosis [ELF] test). See the section on assessment for advanced liver fibrosis in the NICE guideline on NAFLD. [2016]

1.1.5 Consider liver biopsy to diagnose cirrhosis in people for whom transient elastography is not suitable. [2016]

1.1.6 Do not offer tests to diagnose cirrhosis for people who are living with obesity (BMI of 30 kg/m2 or higher), or who have type 2 diabetes, unless they have NAFLD and advanced liver fibrosis (as diagnosed by a score of 10.51 or above using the ELF test). See the section on assessment for advanced liver fibrosis in the NICE guideline on NAFLD. [2016]

1.1.7 Ensure that healthcare professionals who perform or interpret non‑invasive tests are trained to do so. [2016]

1.1.8 Do not use routine laboratory liver blood tests to rule out cirrhosis. [2016]

1.1.9 Refer people diagnosed with cirrhosis to a specialist in hepatology. [2016]

1.1.10 Offer retesting for cirrhosis every 2 years for:

1.2 Monitoring

Risk of complications

1.2.1 Refer people who have, or are at high risk of, complications of cirrhosis to a specialist hepatology centre. [2016]

1.2.2 Calculate the Model for End‑Stage Liver Disease (MELD) score every 6 months for people with compensated cirrhosis. [2016]

1.2.3 Consider using a MELD score of 12 or more as an indicator that the person is at high risk of complications of cirrhosis. [2016]

Hepatocellular carcinoma

1.2.4 Offer ultrasound (with or without measurement of serum alpha-fetoprotein) every 6 months as surveillance for hepatocellular carcinoma (HCC) for people with cirrhosis who do not have hepatitis B virus infection. [2016]

1.2.5 Do not offer surveillance for HCC for people who are receiving end of life care. [2016]

For people with cirrhosis and hepatitis B virus infection, see the section on surveillance testing for HCC in adults with chronic hepatitis B in the NICE guideline on chronic hepatitis B.

Oesophageal varices

1.2.6 After a diagnosis of cirrhosis, offer the person an upper gastrointestinal endoscopy to detect oesophageal varices unless they are planning to take carvedilol or propranolol to prevent decompensation (see the section on primary prevention of decompensation). [2016, amended 2023]

1.2.7 Offer surveillance using upper gastrointestinal endoscopy every 3 years to people who:

  • have already had an endoscopy to detect oesophageal varices, and in whom none have been found and

  • are not taking carvedilol or propranolol. [2016, amended 2023]

1.2.8 Consider simultaneous endoscopic variceal band ligation if medium or large varices are detected during upper gastrointestinal endoscopy (see the section on preventing bleeding from medium or large oesophageal varices). [2023]

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on oesophageal varices.

Full details of the evidence and the committee's discussion are in evidence review A: clinical and cost effectiveness of non-selective beta-blockers and endoscopic variceal band ligation for the primary prevention of bleeding in people with oesophageal varices due to cirrhosis.

1.3 Managing complications

Safe prescribing and use of carvedilol and propranolol in people with cirrhosis

1.3.1 Be aware that:

  • carvedilol and propranolol should be used with caution in people with cirrhosis because these medicines can have a greater effect on their heart rate and blood pressure

  • carvedilol should be avoided in people with severe hepatic impairment (for example, in those with large-volume or refractory ascites). [2023]

1.3.2 When starting treatment with either carvedilol or propranolol in people with cirrhosis to prevent decompensation, or bleeding from medium or large varices:

  • use a low dosage (for example, 6.25 mg a day for carvedilol or 40 mg twice a day for propranolol) and

  • increase or decrease the dose depending on the results of heart and blood pressure monitoring. [2023]

    In September 2023, the use of the following was off-label:

  • carvedilol and propranolol for the primary prevention of decompensation

  • carvedilol for preventing variceal bleeding.

    See NICE's information on prescribing medicines.

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on safe prescribing and use of carvedilol and propranolol in people with cirrhosis.

Full details of the evidence and the committee's discussion are in:

Primary prevention of decompensation

1.3.3 For people who have cirrhosis and confirmed, or suspected, clinically significant portal hypertension (for example, as indicated by a hepatic venous pressure gradient of more than 10 mmHg or the presence of oesophageal varices), consider the following options for the primary prevention of decompensation:

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on primary prevention of decompensation.

Full details of the evidence and the committee's discussion are in evidence review C: clinical and cost effectiveness of non-selective beta-blockers for the primary prevention of decompensation in people with compensated cirrhosis.

Preventing bleeding from medium or large oesophageal varices

1.3.4 If the person with cirrhosis has medium or large oesophageal varices:

  • discuss the benefits and harms of all treatment options in line with NICE's guidelines on shared decision making and patient experience in adult NHS services

  • explain what treatment involves and ask about any potential barriers that could prevent them from accessing treatment (for example, they may find it difficult to take tablets regularly because they are dependent on alcohol or are experiencing homelessness). [2023]

1.3.5 For people with medium or large oesophageal varices, offer:

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on preventing bleeding from medium or large oesophageal varices.

Full details of the evidence and the committee's discussion are in evidence review A: clinical and cost effectiveness of non-selective beta-blockers and endoscopic variceal band ligation for the primary prevention of bleeding in people with oesophageal varices due to cirrhosis.

Preventing spontaneous bacterial peritonitis

1.3.6 Do not routinely offer antibiotics to prevent spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites. [2023]

1.3.7 Consider antibiotics to prevent SBP only if:

  • the person is at high risk of developing SBP because they have severe liver disease (for example, they have an ascitic protein of 15 g per litre or less, a Child–Pugh score of more than 9, or a MELD score of more than 16) or

  • the consequences of an infection could seriously impact the person's care, for example, if it could affect their wait for a transplant or a transjugular intrahepatic portosystemic stent insertion (TIPS). [2023]

1.3.8 When offering antibiotics to prevent SBP:

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on preventing SBP.

Full details of the evidence and the committee's discussion are in evidence review B: use of antibiotics to prevent SBP.

Treatment for upper gastrointestinal bleeding

1.3.9 Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding. [2016]

1.3.10 Review the use of intravenous antibiotics prescribed for upper gastrointestinal bleeding in line with the section on prescribing intravenous antimicrobials in the NICE guideline on antimicrobial stewardship. [2016]

Treating refractory ascites

1.3.11 Consider a TIPS procedure for people with cirrhosis who have refractory ascites. [2016]

  • National Institute for Health and Care Excellence (NICE)