Cirrhosis in over 16s: assessment and management

Diagnosis

• Be aware that there is an increased risk of cirrhosis in people who:
  • have hepatitis B virus infection
  • have hepatitis C virus infection
  • misuse alcohol
  • are obese (BMI of 30 kg/m2 or higher)
  • have type 2 diabetes
• Also see the NICE guidelines on: non-alcoholic fatty liver disease (NAFLD), alcohol-use disorders: diagnosis and management of physical complications, alcohol-use disorders: prevention, alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, type 2 diabetes in adults, obesity and hepatitis B (chronic)
• Discuss with the person the accuracy, limitations and risks of the different tests for diagnosing cirrhosis
• Offer transient elastography to diagnose cirrhosis for:
  • people with hepatitis C virus infection
  • men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week and have done so for several months
  • people diagnosed with alcohol-related liver disease
• 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). Also see the assessment for advanced liver fibrosis section in NICE's NAFLD guideline
• Consider liver biopsy to diagnose cirrhosis in people for whom transient elastography is not suitable
• For recommendations on diagnosing cirrhosis in people with hepatitis B virus infection, see the assessment of liver disease in secondary specialist care section in NICE's hepatitis B (chronic) guideline
• Do not offer tests to diagnose cirrhosis for people who are obese (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). Also see the assessment for advanced liver fibrosis section in NICE's NAFLD guideline
• Ensure that healthcare professionals who perform or interpret non‑invasive tests are trained to do so
• Do not use routine laboratory liver blood tests to rule out cirrhosis
• Refer people diagnosed with cirrhosis to a specialist in hepatology
• Offer retesting for cirrhosis every 2 years for:
  • people diagnosed with alcohol-related liver disease
  • people with hepatitis C virus infection who have not shown a sustained virological response to antiviral therapy
  • people with NAFLD and advanced liver fibrosis
• For recommendations on reassessing liver disease in hepatitis B virus infection, see the assessment of liver disease in secondary specialist care section in NICE's hepatitis B (chronic) guideline

Monitoring

Risk of complications

• Refer people who have, or are at high risk of, complications of cirrhosis to a specialist hepatology centre
• Calculate the Model for End‑Stage Liver Disease (MELD) score every 6months for people with compensated cirrhosis
• Consider using a MELD score of 12 or more as an indicator that the person is at high risk of complications of cirrhosis

Hepatocellular carcinoma

• 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
• For people with cirrhosis and hepatitis B virus infection, see the surveillance testing for hepatocellular carcinoma in adults with chronic hepatitis B section in NICE's hepatitis B (chronic) guideline
• Do not offer surveillance for HCC for people who are receiving end of life care

Oesophageal varices

• After a diagnosis of cirrhosis, offer upper gastrointestinal endoscopy to detect oesophageal varices
• For people in whom no oesophageal varices have been detected, offer surveillance using upper gastrointestinal endoscopy every 3 years

Managing complications

• Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices
• Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding
• Review intravenous antibiotics prescriptions in line with the prescribing intravenous antimicrobials section in NICE's antimicrobial stewardship guideline
• Consider a transjugular intrahepatic portosystemic shunt for people with cirrhosis who have refractory ascites
• Offer prophylactic oral ciprofloxacin or norfloxacin^* for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved

*At the time of publication (July 2016), neither ciprofloxacin nor norfloxacin had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines—guidance for doctors for further information.