In this blog Dr Dina Mansour explains what is covered in the new guidelines.
The British Society of Gastroenterology, in partnership with the British Association for Study of Liver, the British Liver nurse association and the British Liver Trust have recently published new guidelines on the outpatient management of cirrhosis. The guidance is written in three parts.
Part 1 part covers how people with 'compensated cirrhosis' should be managed in clinic.
Someone with compensated cirrhosis has scarring of the liver. But does not have any of the complications of liver disease, and their livers are still working well.
The main aim of managing compensated cirrhosis is to:
- Prevent further liver damage.
Including avoiding alcohol.
- Monitor for complications.
Such as veins in the gullet (known as varices) and liver cancer.
- Support the patients' overall health.
This includes ensuring patients are up to date with vaccinations. Screening for and treating osteoporosis (thinning of the bones), as people with cirrhosis can be at increased risk of broken bones. And offering tailored advice on diet and exercise.
The guidance includes a checklist for health professionals to help them cover all the aspects of care.
Part 2 part of the guidance covers how to manage people with decompensated cirrhosis.
People with decompensated cirrhosis have more advanced disease. They have complications or symptoms such as:
- fluid in the tummy (ascites).
- yellow skin and eyes (jaundice).
- confusion (encephalopathy).
In people with this advanced disease, we need to consider whether we can do anything to stop or reverse the liver damage. For example stopping alcohol or treating viral hepatitis.
We also want to prevent further complications such as bleeding from varices (veins in the gullet or stomach).
If not, liver transplantation may be needed. Not all patients are suitable for liver transplant. Because these patients can have a lot of symptoms, supportive (or palliative) care needs to be considered. This can help manage symptoms and improve quality of life, whether or not patients are suitable for transplant.
The guidance covers how to:
- Manage fluid build-up in the tummy.
Including regular drains if needed.
- Avoid unplanned hospital admissions.
By keeping a close eye on people in clinic.
- Assess and treat confusion.
Caused by the build-up of toxins in the brain due to liver disease (encephalopathy).
Patients with very advanced liver disease also need a lot of calories and protein, as their bodies use much more energy than healthy people. Making sure patients have a good diet and supplement drinks if needed can help prevent them becoming frail and weak. Input from dieticians is important to support this.
Part 3 covers special cases that might be faced in managing people with cirrhosis in clinic.
This includes how to manage and monitor people with cirrhosis who wish to, or become pregnant, or who need surgery. And how to advise patients who wish to travel.
People with liver disease often have problems with clotting. They can be more likely to bleed, but also more likely to form clots. The guidance covers what to do if patients with cirrhosis undergo procedures where there is a risk of bleeding. And how to manage clots in the blood vessel that carries blood from the gut to the liver (the portal vein).
The guidance also talks about the kind of information patients should be given when diagnosed with cirrhosis. And explains the importance of patients having access to the liver team (such as specialist nurses). The team can provide advice, urgent review and ascitic drains as a day case where needed.
Looking after people with cirrhosis requires a team of healthcare professionals working closely with patients and carers. This guidance aims to help standardise and improve outpatient care across the country.
You can find out more about liver cirrhosis on our condition page here.
You can find the new guidelines online here:
NICE have also updated their cirrhosis guidelines which broadly align NICE guidelines
Dr Dina Mansour MBBS (hons) MA Cantab
Dr Dina Mansour is a consultant Gastroenterologist and Clinical lead for Gastroenterology and Hepatology at Queen Elizabeth hospital in Gateshead. She was project lead for the new BSG guidelines.