Preventive care takes center stage in new cirrhosis guideline

Clinical takeaway: Preventive care should be treated as a cornerstone of cirrhosis management, not an afterthought. The guideline highlights several actionable interventions, including carvedilol for portal hypertension and high-risk varices, routine HCC surveillance, vaccination, alcohol-use disorder treatment, and structured nutrition and exercise programs.

The American College of Gastroenterology (ACG) has released its first comprehensive guideline on preventive care for cirrhosis, bringing together 18 recommendations and six key concepts that span cirrhosis-specific complications, infection prevention, lifestyle interventions, and management of non-liver complications. The goal is to standardize evidence-based practices that can reduce hospitalizations, improve quality of life, and prolong survival.

Among the strongest recommendations is the use of carvedilol or endoscopic variceal ligation for primary prevention of bleeding in patients with high-risk esophageal varices. The guideline also suggests carvedilol for patients with compensated cirrhosis and clinically significant portal hypertension to reduce the risk of first-onset ascites, reinforcing carvedilol's growing role beyond variceal prophylaxis.

For hepatic encephalopathy, the guideline suggests lactulose in patients with minimal hepatic encephalopathy to prevent progression to overt disease. In patients who develop overt hepatic encephalopathy despite lactulose therapy, adding rifaximin is recommended to reduce recurrence, particularly following hospitalization. However, rifaximin is not recommended as primary prevention in patients with minimal hepatic encephalopathy.

The document also addresses prevention of decompensation and liver cancer. Patients with cirrhosis who are candidates for treatment should undergo hepatocellular carcinoma surveillance with liver ultrasound plus alpha-fetoprotein testing every six months. The guideline advises against prescribing aspirin solely for HCC prevention and similarly recommends against using statins exclusively for HCC chemoprevention in the absence of standard cardiovascular indications.

Several recommendations focus on infection prevention. The authors strongly recommend testing for hepatitis A immunity and vaccinating susceptible patients, along with routine influenza, COVID-19, and RSV vaccination. Testing for hepatitis B immunity and vaccination are also encouraged, with revaccination strategies considered for patients who fail to mount adequate immune responses.

Lifestyle interventions are highlighted as key components of cirrhosis care. The guideline supports post-discharge behavioral therapy for patients with alcohol use disorder, routine screening for unhealthy alcohol use, and consideration of pharmacologic treatment such as naltrexone or acamprosate when appropriate. It also recommends dietitian-guided nutrition programs with adequate protein and calorie intake and structured aerobic and resistance exercise to combat frailty and sarcopenia.

Beyond liver-specific care, the guideline calls attention to osteoporosis, a frequently overlooked complication. Clinicians are encouraged to screen for osteoporosis and consider bisphosphonate therapy when indicated. Notably, the presence of esophageal or gastric varices alone should not be viewed as a contraindication to oral bisphosphonate treatment.

The authors emphasize that many of these interventions are relatively simple and can be integrated into routine practice through multidisciplinary care and clinical decision-support tools. They conclude, “The care of patients with cirrhosis is optimized when preventive measures are reliably applied.”

Key Recommendations

• Use carvedilol or endoscopic variceal ligation for primary prevention of bleeding in patients with high-risk esophageal varices.
• Perform HCC surveillance with liver ultrasound and alpha-fetoprotein testing every 6 months in eligible patients.
• Vaccinate against hepatitis A, influenza, COVID-19, and RSV; assess and address hepatitis B immunity.
• Consider lactulose for minimal hepatic encephalopathy and add rifaximin for recurrence prevention after overt episodes despite lactulose.
• Use short-course (2-3 day) antibiotic prophylaxis during upper GI bleeding episodes in patients with cirrhosis.
• Promote treatment of alcohol use disorder, nutrition counseling, structured exercise, and smoking cessation.
• Screen for osteoporosis and consider bisphosphonate therapy when indicated.

Source: Tapper EB, et al. (2026 Oct 5) Am J Gastroenterol. ACG Clinical Guideline: Preventive Care for Patients With Cirrhosis