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Liver cirrhosis

What's new

The American College of Gastroenterology (ACG) has released new recommendations on nutritional interventions in chronic liver disease. Early oral or enteral nutrition is suggested in hospitalized patients with cirrhosis. Nutritional supplementation is also suggested in cirrhosis and alcohol-associated hepatitis. Protein restriction is not recommended in hepatic encephalopathy; instead, vegetarian protein sources and branched-chain amino acids are suggested. Late evening snacks are recommended to improve BMI, muscle mass, and reduce complications. Coffee consumption (≥2 cups/day) is suggested to lower risk of fibrosis progression and HCC. No recommendation is made regarding sodium restriction in cirrhosis with ascites on diuretics due to insufficient evidence. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of liver cirrhosis are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2025,2023,2021,2018,2017,2014), the American College of Gastroenterology (ACG 2025,2022,2020), the American Gastroenterological Association (AGA 2025,2023,2021,2017), the European Association for the Study of the Liver (EASL 2025,2022,2018,2016), the British Society ...
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Classification and risk stratification

Risk stratification: as per AASLD 2017 guidelines, describe, analyze, and manage cirrhosis in two distinct clinical stages, compensated and decompensated, defined by the presence or absence of overt clinical complications of cirrhosis (ascites, variceal hemorrhage, and hepatic encephalopathy).
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Diagnostic investigations

Evaluation of fibrosis, general principles: as per AASLD 2025 guidelines, consider incorporating imaging-based noninvasive liver disease assessment into the initial fibrosis staging process in adult patients with chronic liver disease, as it is more accurate than blood-based noninvasive liver disease assessment.
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  • Evaluation of fibrosis (hepatitis C)

  • Evaluation of fibrosis (hepatitis B)

  • Evaluation of fibrosis (ALD)

  • Evaluation of fibrosis (MASLD)

  • Evaluation of fibrosis (compensated cirrhosis)

  • Evaluation of fibrosis (preoperative assessment)

  • Evaluation of fibrosis (monitoring)

  • Evaluation of ascites

  • Evaluation of portal hypertension

  • Evaluation of gastroesophageal varices

  • Evaluation of variceal hemorrhage

  • Evaluation of portal vein thrombosis

  • Evaluation of DVT

  • Evaluation of SBP

  • Evaluation of hepatopulmonary syndrome

  • Evaluation of portopulmonary hypertension

  • Evaluation of renal impairment

  • Evaluation of hepatic encephalopathy

  • Evaluation of cardiac complications

  • Evaluation of relative adrenal insufficiency

  • Evaluation of sarcopenia and frailty

  • Evaluation of malignancy

Medical management

General principles: as per EASL 2018 guidelines, identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection.
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  • Fluid management

  • Management of ascites (diuretic therapy)

  • Management of ascites (intravenous albumin)

  • Management of ascites (other agents)

  • Management of ascites (therapeutic paracentesis)

  • Management of ascites (TIPS)

  • Management of ascites (implantable peritoneal pump)

  • Management of ascites (refractory ascites)

  • Management of bacterascites

  • Management of hepatic hydrothorax

  • Management of portal hypertensive gastropathy

  • Prevention of gastroesophageal varices

  • Prevention of variceal hemorrhage (primary prevention)

  • Prevention of variceal hemorrhage (gastric varices)

  • Prevention of variceal hemorrhage (secondary prevention)

  • Management of variceal hemorrhage (pharmacotherapy)

  • Management of variceal hemorrhage (blood product transfusion)

  • Management of variceal hemorrhage (endoscopic therapy)

  • Management of variceal hemorrhage (TIPS)

  • Management of variceal hemorrhage (balloon-occluded retrograde transvenous obliteration)

  • Management of variceal hemorrhage (balloon tamponade)

  • Management of variceal hemorrhage (Sengstaken-Blakemore tube)

  • Management of variceal hemorrhage (gastric varices)

  • Management of variceal hemorrhage (surveillance)

  • Management of coagulopathy

  • Management of portal vein thrombosis

  • Prevention of DVT

  • Management of DVT

  • Prevention of SBP (primary prevention)

  • Prevention of SBP (secondary prevention)

  • Management of SBP (antibiotic therapy)

  • Management of SBP (intravenous albumin)

  • Management of SBP (vasoactive agents)

  • Management of SBP (medications to avoid)

  • Management of other infections (evaluation)

  • Management of other infections (antibiotic therapy)

  • Management of other infections (intravenous albumin)

  • Management of hepatopulmonary syndrome

  • Management of portopulmonary hypertension

  • Management of hepatorenal syndrome (pharmacotherapy)

  • Management of hepatorenal syndrome (RRT)

  • Management of hepatorenal syndrome (therapeutic paracentesis)

  • Management of hepatorenal syndrome (TIPS)

  • Management of hepatic encephalopathy

  • Management of hyponatremia

  • Management of anemia

  • Management of relative adrenal insufficiency

  • Prevention of sarcopenia and frailty

  • Management of sarcopenia and frailty

  • Medications to avoid

Nonpharmacologic interventions

Physical activity: as per AASLD 2021 guidelines, offer physical activity-based interventions involving the following components to improve muscle contractile function and muscle mass in patients with cirrhosis:
assessment and reassessment of frailty and/or sarcopenia with standardized tools
a combination of aerobic and resistance exercises
tailored recommendations based on assessments.
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  • Weight loss

  • Nutrition (general principles)

  • Nutrition (calories)

  • Nutrition (fructose)

  • Nutrition (proteins)

  • Nutrition (vitamins and micronutrients)

  • Salt restriction

  • Fluid restriction

  • Coffee consumption

  • Inpatient nutrition

Perioperative care

Assessment of procedural bleeding risk: as per EASL 2022 guidelines, recognize that INR and aPTT do not predict post-procedural bleeding in patients with cirrhosis undergoing invasive procedures.
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  • Prevention of procedural bleeding

Surgical interventions

Liver transplantation: as per AASLD 2021 guidelines, consider referring patients with grade 2 or 3 ascites for evaluation for liver transplantation.
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  • Elective hernia repair

Specific circumstances

Pediatric patients: as per AASLD 2025 guidelines, consider obtaining simple, cost-effective, and readily available blood-based noninvasive liver disease assessments, such as APRI or FIB-4, for the detection of advanced fibrosis (F3-4) in pediatric patients with chronic liver disease.
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  • Patients with obesity

  • Patients with acute-on-chronic liver failure (diagnosis)

  • Patients with acute-on-chronic liver failure (management)

Follow-up and surveillance

Surveillance for malignancy: as per BSG 2024 guidelines, consider obtaining surveillance for HCC with 6-monthly ultrasound and α-fetoprotein measurement in patients with liver cirrhosis.
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