Cirrhosis in Over 16s: Assessment and Management

Overview

This Guidelines summary covers the assessment and management of suspected or confirmed cirrhosis in people who are 16 years or older. This summary is intended for use by primary healthcare professionals. Refer to the full guideline for a complete set of recommendations, including managing complications.

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 living with obesity (body mass index [BMI] of 30 kg/m² or higher)
  • have type 2 diabetes.
• See NICE’s 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 (high-risk drinking) and alcohol dependence, type 2 diabetes in adults, obesity, and chronic hepatitis B.
• 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 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.
• 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 section in the NICE guideline on NAFLD.
• Consider liver biopsy to diagnose cirrhosis in people for whom transient elastography is not suitable.
• 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). See the section on assessment for advanced liver fibrosis section in the NICE guideline on NAFLD.
• 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.

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 6 months 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.
• Do not offer surveillance for HCC for people who are receiving end of life care.

Oesophageal Varices

• 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 in the full guideline).
• 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.
• 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 in the full guideline). 

For recommendations on managing complications, refer to the full guideline.