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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cirrhosis: diagnosis and staging

Gastroenterology and hepatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

New ascites, gastrointestinal bleeding, jaundice, hepatic encephalopathy, sepsis or acute kidney injury marks decompensation and warrants same-day hospital assessment. Haematemesis requires the major upper-GI bleed pathway; fever or pain with ascites requires urgent diagnostic paracentesis; altered mental state needs glucose, infection, bleeding, medicine and intracranial assessment rather than automatic attribution to hepatic encephalopathy. Apply the BSG/BASL decompensated-cirrhosis bundle in the first twenty-four hours and involve a liver or transplant service early when organ failure progresses.

Synopsis

Confirm cirrhosis, identify its cause and separate compensated from decompensated disease so surveillance, prevention and transplant planning begin promptly.

  • Cirrhosis is advanced diffuse hepatic fibrosis with architectural distortion, regenerative nodules and clinically important risks even when routine liver tests are near normal.
  • Diagnosis increasingly uses a concordant combination of aetiology, platelets, imaging and elastography; biopsy is reserved for uncertainty that changes management.
  • FIB-4 and similar scores are triage tools for advanced fibrosis, not definitive proof or exclusion in every age, disease or acute inflammatory state.
  • Compensated cirrhosis has no prior ascites, variceal haemorrhage or overt encephalopathy; decompensation is a prognostic watershed requiring transplant consideration.
  • Clinically significant portal hypertension can precede varices or ascites and is now a prevention target in current NICE and BSG pathways.
  • Child-Pugh uses bilirubin, albumin, INR, ascites and encephalopathy but contains subjective elements and should not be used alone.
  • MELD-based and UKELD scores support short-term prognosis and transplant allocation or referral; a score supplements clinical trajectory rather than replacing it.
  • Aetiology must remain active after the label cirrhosis: alcohol, viral hepatitis, metabolic steatosis, autoimmune, cholestatic, vascular and inherited causes may be treatable.
  • People with cirrhosis need six-monthly ultrasound HCC surveillance when suitable for treatment, plus portal, bone, nutrition, vaccination and medicine-safety review.
  • Normal ALT, albumin or an unremarkable examination cannot de-label previously established cirrhosis or remove surveillance obligations.

Key red flags

Ascitic decompensation

Increasing abdominal girth, early satiety, ankle oedema, breathlessness or an umbilical hernia signals fluid retention and requires diagnostic paracentesis when new or admitted.

Overt hepatic encephalopathy

Sleep reversal, slowed thinking, disorientation, asterixis or coma occurs after triggers such as infection, bleeding, constipation, dehydration, sedatives or renal dysfunction.

Portal gastrointestinal bleed

Haematemesis, melaena, syncope or shock in cirrhosis is variceal until urgent resuscitation and endoscopy define the source.

Acute-on-chronic deterioration

New jaundice, kidney injury, hypotension, hypoxia or multiple organ dysfunction after infection, alcohol, bleeding or drug injury carries high short-term risk.

Investigation priorities

01
Full liver and synthetic profileFirst step

Assess injury, cholestasis and functional reserve.

Management branches

ConfirmationDiagnose architecture and cause together

Clinical, laboratory or imaging features suggest advanced chronic liver disease.

  1. Review alcohol, metabolic, viral, autoimmune, cholestatic, vascular, inherited and medicine causes and obtain a targeted aetiology panel.
  2. Combine platelets, validated fibrosis score, elastography and ultrasound rather than allowing one normal or abnormal result to dominate.
  3. Use specialist imaging or liver biopsy when discordance would alter treatment, surveillance or the certainty communicated to the patient.
  4. Once cirrhosis is established, record aetiology and phase explicitly and activate surveillance immediately rather than waiting for symptoms.
Ongoing surveillancePrevent avoidable decompensation

The person returns to stable outpatient care after diagnosis or admission.

  1. Maintain six-monthly HCC surveillance and the current portal-hypertension plan, tracking every appointment through a fail-safe system.
  2. Review causal therapy, alcohol and smoking, weight and diabetes, vaccinations, nutrition and physical function at structured intervals.
  3. Monitor bilirubin, albumin, INR, sodium, creatinine and platelets and respond to trajectory, not just whether values cross the reference range.

Key medicines

Non-selective beta-blocker in selected CSPHWhen the current NICE and specialist portal pathway selects carvedilol, begin with a low dose such as 6.25 mg daily and titrate against pulse, blood pressure, renal function and tolerance; do not apply a universal target in unstable disease.Review asthma, heart block, falls, hypotension and interacting rate-limiting medicines. With sepsis, acute kidney injury, severe hyponatraemia or low perfusion, seek hepatology advice about temporary reduction or withholding and planned restart.
Lactulose for overt hepatic encephalopathyUse the current BNF and local encephalopathy regimen, titrating oral or enteral doses to regular soft bowel motions after obstruction is excluded and adjusting promptly for diarrhoea or dehydration.Do not use altered mental state as diagnostic proof of encephalopathy. Over-treatment causes hypovolaemia, hypernatraemia or hypokalaemia and may worsen cognition; protect the airway before enteral administration in reduced consciousness.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG50 cirrhosis recommendationsUK diagnosis, non-invasive testing, HCC surveillance and portal prevention recommendations.
  • BSG compensated cirrhosis outpatient guidanceCare bundle for HCC, varices, bone, vaccination and lifestyle in compensated disease.
  • BSG decompensated cirrhosis outpatient guidanceAscites, encephalopathy, nutrition, transplantation and palliative-care framework.
  • BSG BASL decompensated cirrhosis admission bundleCurrent first twenty-four-hour UK acute assessment and treatment bundle.
  • BSG RCR RCPath liver biopsy guidelineWhen and how histology adds safely after non-invasive staging.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting review
Revisit transplant suitability after first decompensation, recurrent admission, worsening frailty or a prognostic-score change rather than at a fixed terminal point.
JurisdictionUnited Kingdom