There is no treatment that reverses liver cirrhosis.
There are treatments that may slow down the development of various types of liver cirrhosis, for example (1):
- alcohol abstinence for alcoholic hepatitis
- venesection for haemochromatosis
- steroids for autoimmune chronic active hepatitis
Complications of liver cirrhosis, e.g. ascites, variceal haemorrhage and hepatic encephalopathy are managed appropriately.
Monitoring risk of complications (2):
- 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
Monitoring for risk of hepatocellular carcinoma (2)
- 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:
- perform 6-monthly surveillance for HCC by hepatic ultrasound and alpha-fetoprotein testing in people with significant fibrosis (METAVIR stage greater than or equal to F2 or Ishak stage greater than or equal to 3) or cirrhosis
- in people without significant fibrosis or cirrhosis (METAVIR stage less than F2 or Ishak stage less than 3), consider 6-monthly surveillance for HCC if the person is older than 40 years and has a family history of HCC and HBV DNA greater than or equal to 20,000 IU/ml
- do not offer surveillance for HCC in people without significant fibrosis or cirrhosis (METAVIR stage less than F2 or Ishak stage less than 3) who have HBV DNA less than 20,000 IU/ml and are younger than 40 years
- do not offer surveillance for HCC for people who are receiving end of life care
Monitoring for oesophageal varices (2)
- after a diagnosis of cirrhosis, upper gastrointestinal endoscopy should be offered to detect oesophageal varices unless they are planning to take carvedilol or propranolol to prevent decompensation
- for people in whom no oesophageal varices have been detected, offer surveillance using upper gastrointestinal endoscopy every 3 years
- 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
Propranol may reduce the risk of variceal haemorrhage.
Liver transplantation should be considered for patients with end-stage liver cirrhosis
- liver transplantation improves survival of patients with end-stage (Child-Pugh stage C) alcoholic cirrhosis
- listing for liver transplantation did not show a survival benefit compared with standard care for Child-Pugh stage B alcoholic cirrhosis. In addition, immediate listing for transplantation increased the risk for extrahepatic cancer (1)
Safe prescribing and use of carvedilol and propranolol in people with cirrhosis (2)
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)
Primary prevention of decompensation
- 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
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
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