Cirrhosis in over 16s: assessment and management

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

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

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

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]

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.

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]

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]

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]

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]

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 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:

• carvedilol as the first-choice treatment, because it has fewer side effects and a greater effect on portal vein pressure or

• propranolol as the second-choice treatment, if carvedilol is contraindicated.
  
  Follow the section on safe prescribing and use of carvedilol and propranolol in people with cirrhosis. [2023]
  
  In September 2023, the use of carvedilol and propranolol for the primary prevention of decompensation was off-label. See NICE's information on prescribing medicines.

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]

For people with medium or large oesophageal varices, offer:

• carvedilol or propranolol or

• endoscopic variceal band ligation, if either carvedilol or propranolol are not tolerated or contraindicated, or the person cannot take tablets regularly because of their circumstances.
  
  Follow the section on safe prescribing and use of carvedilol and propranolol in people with cirrhosis. [2023]
  
  In September 2023, the use of carvedilol for preventing variceal bleeding was off-label. See NICE's information on prescribing medicines.

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

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]

When offering antibiotics to prevent SBP:

• follow local microbiological advice (in line with NICE's guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use)

• continue with treatment until the ascites is resolved. [2023]

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

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]

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