ACG Guideline Sets 18 Preventive Care Recommendations for Cirrhosis

The American College of Gastroenterology (ACG) has issued a new guideline on preventive care for patients with cirrhosis. It strongly recommends carvedilol or variceal ligation for high-risk varices, semiannual hepatocellular carcinoma (HCC) surveillance, and routine vaccination.¹

The guidance includes 18 graded recommendations and 6 key concept statements across 4 domains: cirrhosis-specific complications, infection prevention, lifestyle factors, and conditions outside the liver. A panel of hepatology experts and 2 GRADE methodologists developed it. Cirrhosis affects >2 million Americans, and the authors noted that even patients with decompensated disease can recompensate when best practices are applied.¹

"The care of patients with cirrhosis is optimized when preventive measures are reliably applied," Elliot B. Tapper, MD, and colleagues wrote.¹ Most of the evidence supporting the recommendations was rated as low certainty.

Carvedilol, Variceal Ligation, and Semiannual HCC Surveillance

The guideline strongly recommends carvedilol or endoscopic variceal ligation (EVL) as primary prophylaxis in patients with high-risk esophageal varices. This was the only recommendation supported by evidence of moderate certainty.¹

The authors identified 12.5 mg daily as the optimal carvedilol dose. They noted that titrating to pulse targets is not appropriate because the drug's effect does not depend on heart rate.¹

For patients with compensated cirrhosis and clinically significant portal hypertension (CSPH), the panel conditionally suggests carvedilol to reduce the first episode of ascites. CSPH may be estimated noninvasively with transient elastography and platelet count.¹ HCPLive's Liver Lineup podcast covered recent advances in portal hypertension and cirrhosis management earlier this year.

The panel strongly recommends HCC surveillance with liver ultrasound and alpha fetoprotein every 6 months in patients who are candidates for HCC therapy. It recommends against aspirin for HCC prevention. A key concept statement also advises against starting statins solely for chemoprevention when patients have no conventional cardiovascular indication.¹

Lactulose, Rifaximin, and Shorter Antibiotic Courses for GI Bleeding

The new guideline builds on ACG's hepatic encephalopathy (HE) guidance from earlier this year. That guideline, published in March 2026, issued 24 recommendations covering ammonia testing, lactulose titration, protein intake, and transplant criteria,² as lead author Jasmohan Bajaj, MD, MS, discussed with HCPLive.

For HE prevention, the new guideline suggests:¹

• Lactulose over no treatment for minimal HE.
• Adding rifaximin for patients who develop overt HE while on lactulose.
• Not using rifaximin as primary prevention of overt HE in patients with minimal HE.

For patients with cirrhosis and upper gastrointestinal (GI) bleeding, the panel suggests 2 to 3 days of prophylactic antibiotics rather than a longer course or none. This applies whether the bleed is variceal or nonvariceal.¹

The authors acknowledged a greater risk of bacterial infection with shorter courses. They weighed this against noninferior mortality, lower cost, and reduced antimicrobial resistance.¹

Key concept statements also advise:¹

• Albumin infusion of 6 to 8 g per liter removed for paracentesis >5 L.
• Follow-up within 14 days after discharge to reduce readmissions and mortality.

Hepatitis A, Influenza, COVID-19, and RSV Vaccination in Cirrhosis

The guideline strongly recommends 4 immunizations:¹

• Hepatitis A immunity testing, with vaccination for patients who are not immune.
• Annual influenza vaccination.
• The SARS-CoV-2 vaccination series.
• The bivalent respiratory syncytial virus (RSV) vaccine for patients ≥50 years.

The panel conditionally suggests hepatitis B immunity testing and vaccination. Patients who remain nonimmune after prior vaccination should be revaccinated, with consideration of the newer Toll-like receptor 9 vaccine.¹

The authors described these as strong recommendations despite evidence of low certainty. They cited each vaccine's established safety profile and its potential to prevent severe infection in this population.¹

Nutrition, Exercise, and Alcohol Use Disorder Treatment

The panel suggests nutrition interventions guided by a dietitian, with daily targets of 1.2 to 1.5 g/kg ideal body weight of protein and 30 to 35 kcal/kg. Lower calorie targets apply for patients with obesity.¹

It also suggests structured aerobic and resistance exercise for ambulatory patients. The authors encouraged pairing exercise with nutrition interventions rather than using either alone.¹

Smoking cessation counseling received a strong recommendation. For patients hospitalized with cirrhosis and alcohol use disorder (AUD), the panel suggests behavioral therapy after discharge. A key concept statement supports AUD screening at each clinical encounter and pharmacotherapy with naltrexone or acamprosate.¹

Bisphosphonates for Osteoporosis and Extrahepatic Cancer Screening

The guideline suggests bisphosphonates for osteoporosis in patients with cirrhosis. The authors stated that esophageal or gastric varices are not, on their own, a contraindication to oral bisphosphonates.¹

Age-appropriate cancer screening should be considered for patients being evaluated or listed for transplant. It should also be considered for nonfrail patients with compensated cirrhosis who have no severe comorbidities limiting life expectancy.¹

Implementing Preventive Cirrhosis Care Through Electronic Health Record Tools and Care Teams

The authors outlined an implementation framework built on 3 pillars: education and dissemination, stakeholder engagement, and practice integration. They called for outreach to both specialists and primary care clinicians.¹

They also suggested that nurses, medical assistants, and coordinators may be best positioned to handle tasks such as vaccination documentation and osteoporosis screening referrals. Electronic best practice advisories and order sets can prompt action at the point of care. The authors cautioned that these alerts must be well targeted to avoid alert fatigue.¹

References

1. Tapper EB, Kardashian A, Debes J, et al. ACG clinical guideline: preventive care for patients with cirrhosis. Am J Gastroenterol. Published online October 5, 2026. doi:10.14309/ajg.0000000000004186

2. Bajaj JS, Jakab SS, Jesudian AB, et al. ACG clinical guideline: hepatic encephalopathy. Am J Gastroenterol. 2026;121(3):588-618. doi:10.14309/ajg.0000000000003899