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]

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.

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:

• 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.

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:

• 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.

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:

• 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]

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]

1. Effectiveness of endoscopic variceal band ligation plus a non-selective beta-blocker for preventing variceal bleeding in people with medium or large oesophageal varices

What is the effectiveness and cost effectiveness of endoscopic variceal band ligation plus a non-selective beta-blocker compared with either of these interventions alone for preventing variceal bleeding in adults with cirrhosis and medium or large oesophageal varices? [2023]

2. Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis

What is the clinical and cost effectiveness of antibiotic prophylaxis to prevent spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites? [2023]

3. Primary prevention of decompensation using non-selective beta-blockers

What is the clinical and cost effectiveness of non-selective beta-blockers for the primary prevention of decompensation in people with compensated cirrhosis and signs of clinically significant portal hypertension from non-invasive tests (such as tests to measure liver stiffness, or biomarkers)? [2023]

4. Assessing the risk of cirrhosis

How can the development of a risk tool help identify people at risk of cirrhosis? [2016]

5. Treating small oesophageal varices

Do non-selective beta-blockers improve survival and prevent first variceal bleeds in people with cirrhosis that is associated with small oesophageal varices? [2016]

6. Antibiotic resistance in treating spontaneous bacterial peritonitis

How frequently does antibiotic resistance occur, and how significant are antibiotic treatment-related complications when antibiotics are used for the primary prevention of SBP in people at high risk of having, or developing, cirrhosis? [2016]

7. Transjugular intrahepatic portosystemic stent

What is the quality of life in people who have had a transjugular intrahepatic portosystemic stent (TIPS)? [2016]

8. Acute hepatic encephalopathy

In people with cirrhosis and an acute episode of hepatic encephalopathy secondary to a clearly identified, potentially reversible precipitating factor, does management of the precipitating event alone improve the hepatic encephalopathy without specific treatment? [2016]

Why the committee made the recommendation

People are usually offered an upper gastrointestinal endoscopy to detect oesophageal varices. If varices are found, they can be treated with either non-selective beta-blockers or endoscopic variceal band ligation. The 2023 update of this guideline recommends carvedilol or propranolol as potential options for preventing decompensation in people who have clinically significant portal hypertension (see the recommendations on primary prevention of decompensation). Therefore, the committee agreed that endoscopy is unnecessary for this group of people because these medicines prevent variceal bleeding. They amended the 2016 recommendations to clarify this.

Based on their knowledge and experience, the committee agreed that endoscopy presents an opportunity to carry out one-off endoscopic variceal band ligation on medium or large varices at the same time. This is because the equipment and preparation are the same for both procedures. They noted that it may not always be possible to offer the endoscopic variceal band ligation during endoscopy because some healthcare professionals will not be trained, or have experience, in carrying out the procedure.

How the recommendation might affect practice

The additional resource impact of carrying out endoscopic variceal band ligation at the same time as endoscopy, where possible, is expected to be small.

Return to recommendation

Why the committee made the recommendations

Carvedilol and propranolol are commonly used in practice to prevent variceal bleeding. However, the committee noted that healthcare professionals often prefer to prescribe carvedilol because it has anti-alpha adrenergic vasodilatory effects in addition to beta-blockade and is also better tolerated. Both medicines need to be used with caution because they have a much greater effect on the heart rate and blood pressure of people with liver disease than in people who do not have liver disease. The committee further noted that the BNF states carvedilol should be used with caution in people with moderate hepatic impairment and avoided in those with severe hepatic impairment. Based their experience and expertise, the committee agreed that 'moderate' would apply to many people with cirrhosis. They were also aware of a growing body of research suggesting it should not be given to some people with large-volume or refractory ascites, so used this as an example of 'severe' hepatic impairment.

The committee noted that the BNF recommends a lower starting dose for propranolol for preventing variceal bleeding in people with cirrhosis, which the committee agreed to include in the recommendation. The same approach should also be taken with carvedilol; however, the committee were concerned that healthcare professionals may not be aware of this, because this is an off-label use of the medicine. Therefore, they recommended that, when used, carvedilol should also be started at a much lower dose than in people without liver disease and included an example of a suitable dosage in the recommendation to help guide healthcare professionals.

How the recommendations might affect practice

The committee noted that the use of non-selective beta-blockers to prevent decompensation is an emerging practice, but that they are already widely used for preventing variceal bleeding. Health economic analysis shows that the cost of prescribing these medicines is outweighed by savings in terms of preventing decompensation and reducing the number of endoscopic variceal band ligation sessions required.

Return to recommendations

Why the committee made the recommendation

The committee acknowledged that portal hypertension is not measured directly as a matter of routine in the UK, but agreed that clinically significant portal hypertension can be diagnosed on the basis of clinical features (for example, ascites or small varices) as well as through non-invasive methods, including tests to measure liver stiffness, or serum biomarkers.

Emerging evidence on the effectiveness of carvedilol and propranolol in preventing primary decompensation in people with clinically significant portal hypertension is unclear but looks promising. Therefore, the committee agreed that either medicine could be a potential treatment option. In the committee's view, carvedilol may be more effective in reducing pressure in the portal vein because it has anti-alpha adrenergic vasodilatory effects in addition to beta-blockade.

The committee made a recommendation for research on the effectiveness of non-selective beta-blockers in people with clinically significant portal hypertension that has been diagnosed through non-invasive investigations. They also noted that a large, National Institute for Health and Care Research-funded trial, underway in the UK, is looking at the use of carvedilol for this indication. They agreed this evidence could help inform future updates of this guideline.

How the recommendation might affect practice

The committee noted that prescribing non-selective beta-blockers for this indication is a new practice, and that they are not widely used in this way across the NHS. However, health economic analysis shows that the additional cost of prescribing these medicines is outweighed by the savings in terms of preventing decompensation.

Return to recommendation

Why the committee made the recommendations

Non-selective beta-blockers or endoscopic variceal band ligation can be used to prevent oesophageal variceal bleeding. The committee agreed that most people would prefer to take medication instead of undergoing an invasive procedure, especially as this would prevent further hospital visits. However, some will need endoscopic variceal band ligation instead, if they have had adverse reactions to non-selective beta-blockers, find it difficult to take tablets every day, or if the medicines do not work as expected. Therefore, the committee agreed it was important to discuss all treatment options, and talk with the person about their preferences and personal circumstances, to identify the right treatment for them.

The evidence did not distinguish between the clinical effectiveness of non-selective beta-blockers and endoscopic variceal band ligation. However, non-selective beta-blockers were found to be more cost effective when people were able to take these medicines regularly.

The studies did not look at the use of endoscopic variceal band ligation in conjunction with a non-selective beta-blocker to prevent variceal bleeding, which the committee agreed could have an additional benefit. They therefore made a recommendation for research to look at the effectiveness of combining both treatments.

How the recommendations might affect practice

In the committee's experience, both non-selective beta-blockers and endoscopic variceal band ligation are in common use for preventing oesophageal variceal bleeding. These recommendations will increase the use of non-selective beta-blockers to prevent variceal bleeding and should reduce both the use of endoscopic variceal band ligation and the costs associated with that procedure.

Return to recommendations

Why the committee made the recommendations

The committee looked at evidence that compared different types of antibiotics for preventing spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites. They noted that 1 of the antibiotics in the evidence (norfloxacin) was not available in the UK, and that the fluoroquinolone class of antibiotics (which includes ciprofloxacin) was the subject of a 2019 MHRA drug safety update that includes restrictions and precautions for their use.

The evidence did not demonstrate any overall benefit of antibiotic prophylaxis when compared with no prophylactic treatment. Therefore, the committee agreed that antibiotics should not be routinely offered to prevent SBP in people with cirrhosis and ascites, unless they were at high risk of developing the infection, or its impact could be severe. Most of the evidence focused on people who had low ascitic protein count, so this was included as an example of a measure that could be used to identify risk factors. The committee also included other measures for assessing the severity of liver disease.

The committee agreed that, because the evidence showed no overall benefit of using 1 antibiotic over another, prescribers should follow local microbiological advice. This would mean local pathogen distribution would be taken into account and would lead to better antimicrobial stewardship. The committee also noted the importance of good antimicrobial stewardship to reduce the potential emergence of drug-resistant bacteria.

The committee agreed that the evidence was not methodologically robust, the sample sizes were small, and none of the studies looked at quality-of-life data. Therefore, they made a recommendation for research on antibiotic prophylaxis to prevent SBP to encourage studies that are more rigorous and look at clinically important outcomes such as mortality, health-related quality of life, and serious adverse events.

How the recommendations might affect practice

In the committee's experience, there is wide variation in practice in the prescribing of antibiotics for preventing SBP. The 2023 recommendations suggest using antibiotics for people at high risk, but do not specify which antibiotics. This means that antibiotic choice can be based on local microbiological advice and funding agreements, which may reduce the costs of prescribing antibiotics where necessary. It also makes clear that antibiotics are not necessary for everyone with cirrhosis and ascites.

Return to recommendations