ACG Clinical Guideline: Preventive Care for Patients With Cirrhosis

Cirrhosis affects more than 2 million Americans and drives substantial healthcare utilization, impaired quality of life, and mortality. Because early-stage disease carries a favorable prognosis and decompensated patients can recompensate, systematic delivery of preventive care is essential. Under the auspices of the American College of Gastroenterology Practice Parameters Committee, a writing group of hepatology experts and 2 Grading of Recommendations, Assessment, Development, and Evaluation methodologists developed PICO questions, conducted librarian-assisted searches of PubMed, Embase, and the Cochrane Library, and prioritized systematic reviews, meta-analyses, and randomized trials. The resulting guidance comprises 18 Grading of Recommendations, Assessment, Development, and Evaluation-assessed recommendations and 6 key concept statements spanning 4 domains: prevention of cirrhosis-specific complications, infection prevention, lifestyle factors, and non-liver-specific conditions. Strong recommendations include carvedilol or variceal ligation of high-risk esophageal varices, semiannual hepatocellular carcinoma surveillance, hepatitis A testing and vaccination, influenza, severe acute respiratory syndrome coronavirus 2, respiratory syncytial virus immunization, and smoking-cessation counseling. Conditional recommendations address lactulose for minimal hepatic encephalopathy, adjunctive rifaximin after hospitalization, short-course antibiotic prophylaxis for upper gastrointestinal bleeding, postdischarge behavioral therapy for alcohol use disorder, dietitian-guided nutrition, structured exercise, and bisphosphonates for osteoporosis. Most evidence was of low certainty. We provide an implementation framework of education, stakeholder engagement, and practice integration to translate these recommendations into routine care.