NICE NG50 (2023 update): assessment and management of cirrhosis in adults

Who it applies to

Adults aged 16 and over who have, or are at risk of, cirrhosis from any cause, managed in primary and secondary care.

Key recommendations

• Use transient elastography or other validated non-invasive tests to assess liver fibrosis in people with chronic hepatitis C, high alcohol intake, or non-alcoholic fatty liver disease with additional risk factors, rather than relying on liver biopsy as first line.
• For people with non-alcoholic fatty liver disease, fibrosis assessment and risk stratification should follow the dedicated NICE guideline on non-alcoholic fatty liver disease (NG49) rather than this guideline.
• Once cirrhosis is diagnosed, arrange ongoing specialist monitoring that includes clinical assessment and relevant blood tests at regular intervals rather than a one-off evaluation.
• Offer upper gastrointestinal endoscopy to screen for oesophageal varices at diagnosis of cirrhosis, with the interval for repeat screening guided by findings and liver function.
• Use non-selective beta-blockers as a first-line option for primary prevention of variceal bleeding in people with varices, with endoscopic band ligation as an alternative or for those who cannot tolerate beta-blockers.
• Offer six-monthly ultrasound surveillance (with or without alpha-fetoprotein) for hepatocellular carcinoma in all people with cirrhosis.
• Assess for and manage ascites with sodium restriction and diuretics as first-line measures, escalating to large-volume paracentesis with albumin cover when needed.
• Consider antibiotic prophylaxis for selected high-risk groups, such as those with a prior episode of spontaneous bacterial peritonitis or low-protein ascitic fluid, to reduce infection risk.
• Assess all patients with decompensated cirrhosis for possible liver transplantation referral and involve a specialist hepatology team early.
• Provide information and support on nutrition, alcohol cessation where relevant, and vaccination to patients with cirrhosis as part of routine care.

Practice points for students

• Non-invasive fibrosis assessment (e.g. transient elastography) is now preferred over liver biopsy for initial risk stratification in most common causes of chronic liver disease seen under this guideline, such as alcohol-related liver disease and chronic hepatitis C.
• For NAFLD specifically, clinicians should refer to NICE NG49 for fibrosis testing criteria and risk stratification, as NG50 defers to that guideline for this population.
• Six-monthly ultrasound (plus AFP) surveillance for hepatocellular carcinoma applies to essentially all patients with confirmed cirrhosis, regardless of aetiology.
• Non-selective beta-blockers and band ligation are the two main options for primary prevention of variceal haemorrhage once varices are found on screening endoscopy.
• Early specialist referral and transplant assessment should be considered as soon as a patient decompensates, not only at an advanced stage.

Condition

Other guidelines on this topic

• ACG Clinical Guideline: Preventive Care for Patients With CirrhosisACG2026Official guideline
• AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosisAASLD2024Summary
• EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosisEASL2018Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.