Evidence-based clinical practice guidelines for Liver Cirrhosis 2020
JSGE/JSH (hepatology) · 2021 · Japan
Source and licence
- Authors
- Hitoshi Yoshiji, Sumiko Nagoshi, Takemi Akahane et al.
- Title
- Evidence-based clinical practice guidelines for Liver Cirrhosis 2020
- Journal
- Journal of Gastroenterology, 2021
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC8280040
Licence statement of the original publication
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Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
FRQ 1–1. What is the pathogenesis of acute-on-chronic liver failure (ACLF)?
- Statement• ACLF is an acute decompensation stage in patients with liver cirrhosis, which develops and worsens because of some triggers and leads to liver failure within 28 days [14]. Although the exact pathogenesis of ACLF progression is not known, it requires multidisciplinary treatment for multiple organ failure and has a high mortality rate [15]. In Japan, the proposal for the diagnostic criteria for ACLF has been confirmed [16], and nationwide studies will be performed to elucidate the pathogenesis, prognosis, and therapy for ACLF.
CQ4-12. Is treatment necessary for covert hepatic encephalopathy?
- We suggest treating patients with covert hepatic encephalopathy who have a high risk of developing overt hepatic encephalopathy, such as worsening background liver conditions or the presence of symptoms of decompensated cirrhosis other than hepatic encephalopathy.
Abstract
The first edition of the clinical practice guidelines for liver cirrhosis was published in 2010, and the second edition was published in 2015 by the Japanese Society of Gastroenterology (JSGE). The revised third edition was recently published in 2020. This version has become a joint guideline by the JSGE and the Japan Society of Hepatology (JSH). In addition to the clinical questions (CQs), background questions (BQs) are new items for basic clinical knowledge, and future research questions (FRQs) are newly added clinically important items. Concerning the clinical treatment of liver cirrhosis, new findings have been reported over the past 5 years since the second edition. In this revision, we decided to match the international standards as much as possible by referring to the latest international guidelines. Newly developed agents for various complications have also made great progress. In comparison with the latest global guidelines, such as the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD), we are introducing data based on the evidence for clinical practice in Japan. The flowchart for nutrition therapy was reviewed to be useful for daily medical care by referring to overseas guidelines. We also explain several clinically important items that have recently received focus and were not mentioned in the last editions. This digest version describes the issues related to the management of liver cirrhosis and several complications in clinical practice. The content begins with a diagnostic algorithm, the revised flowchart for nutritional therapy, and refracted ascites, which are of great importance to patients with cirrhosis. In addition to the updated antiviral therapy for hepatitis B and C liver cirrhosis, the latest treatments for non-viral cirrhosis, such as alcoholic steatohepatitis/non-alcoholic steatohepatitis (ASH/NASH) and autoimmune-related cirrhosis, are also described. It also covers the latest evidence regarding the diagnosis and treatment of liver cirrhosis complications, namely gastrointestinal bleeding, ascites, hepatorenal syndrome and acute kidney injury, hepatic encephalopathy, portal thrombus, sarcopenia, muscle cramp, thrombocytopenia, pruritus, hepatopulmonary syndrome, portopulmonary hypertension, and vitamin D deficiency, including BQ, CQ and FRQ. Finally, this guideline covers prognosis prediction and liver transplantation, especially focusing on several new findings since the last version. Since this revision is a joint guideline by both societies, the same content is published simultaneously in the official English journal of JSGE and JSH.
Contents of the original publication
The section headings of the original.
- Introduction
- Diagnosis and etiology
- BQ1-1. What is the etiology and pathogenesis of liver cirrhosis?
- FRQ 1–1. What is the pathogenesis of acute-on-chronic liver failure (ACLF)?
- Diagnosis of liver cirrhosis
- BQ 2–1. Are biochemical examination of blood and imaging findings useful for the diagnosis of liver cirrhosis?
- Nutritional therapy
- BQ3-1. Do under-nutrition and obesity affect the prognosis of patients with cirrhosis?
- BQ3-2. Does a late-evening snack (LES) affect the pathological condition of patients with liver cirrhosis?
- BQ3-3. Is the administration of branched-chain amino acids (BCAAs) effective in improving the pathogenesis of liver cirrhosis?
- BQ3-4. What is the recommended energy/protein intake for patients with cirrhosis?
- CQ3-1. Does diabetes affect the pathogenesis of cirrhosis?
- CQ3-2. Do divided meals and eating habits affect the pathology of patients with cirrhosis?
- Antiviral therapy
- Hepatitis B
- Hepatitis C
- Antifibrotic therapy
- Therapy for nonviral liver cirrhosis
- Esophagogastric bleeding and portal hypertension
- BQ4-1. Are red color signs (RC signs) on upper endoscopy a risk factor for esophageal and gastric variceal bleeding?
- BQ4-2. Are abdominal ultrasonography, abdominal contrast-enhanced computed tomography (CE-CT), and magnetic resonance imaging (MRI) useful for the diagnosis of portal hypertension?
- CQ4-1. What drugs are useful to prevent bleeding from esophagogastric varices?
- CQ4-2. Are vasoactive agents effective for the management of esophagogastric variceal bleeding?
- CQ4-3. What drugs are useful for the management of portal hypertensive gastropathy (PHG)?
- CQ4-4. Are acid suppressing drugs useful for preventing gastrointestinal bleeding in patients with cirrhosis?
- CQ4-5. Which is more useful in preventing recurrence of esophageal varices (EV): endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS)?
- CQ4-6. Is balloon-occluded retrograde transvenous obliteration (BRTO) useful for gastric varices and encephalopathy?
- CQ4-7. Does injection of n-butyl cyanoacrylate (NBCA) improve patients’ survival in the treatment for prevention of fundal gastric variceal (GV) bleeding?
- Ascites
- BQ 4–3. What is useful in diagnosis of cirrhotic ascites and spontaneous bacterial peritonitis (SBP)?
- BQ4-4. Is salt restriction effective for ascites associated with cirrhosis?
- BQ4-5. Is albumin infusion effective for treatment of cirrhotic patients with ascites?
- BQ4-6. What is the effective method of administration of spironolactone and loop diuretics for ascites in cirrhosis?
- BQ4-7. Are vasopressin V2 receptor antagonists useful for the management of cirrhotic ascites?
- BQ4-8. Is large-volume paracentesis (LVP) useful for patients with refractory ascites?
- BQ4-9. Is peritoneovenous shunt (PVS) therapy useful for patients with refractory ascites?
- BQ4-10. Does the prognosis of cirrhosis worsen with spontaneous bacterial peritonitis (SBP) or other infections?
- CQ4-8. Are prophylactic antibiotics useful for severely cirrhotic patients with ascites?
- CQ4-9. Is cell-free and concentrated ascites reinfusion therapy (CART) useful for refractory ascites associated with patients with cirrhosis?
- CQ4-10. When is the appropriate time to administer vasopressin V2 receptor antagonist for cirrhotic ascites?
- FRQ 4–1. Are there any factors to predict the effect of vasopressin V2 receptor antagonist for cirrhotic ascites?
- FRQ4-2. Is transjugular intrahepatic portosystemic shunt (TIPS) useful for refractory ascites associated with patients with cirrhosis?
- Hepatorenal syndrome (HRS)
- BQ4-11. Does renal dysfunction worsen the prognosis of patients with liver cirrhosis?
- BQ4-12. Does liver transplantation (LT) improve the prognosis of liver and kidney syndrome?
- CQ4-11. Are there effective drugs for HRS?
- FRQ4-3. Is ultrasonography useful for the diagnosis of HRS?
- FRQ4-4. Are transjugular intrahepatic portosystemic shunts (TIPS) useful for the management of HRS?
- Hepatic encephalopathy
- BQ4-13. Is non-absorbable synthetic disaccharide useful for hepatic encephalopathy?
- BQ4-14. Is a branched-chain amino acid (BCAA)-related medication effective for the management of hepatic encephalopathy?
- CQ4-12. Is treatment necessary for covert hepatic encephalopathy?
- CQ4-13. Are non-absorbable antimicrobials useful for hepatic encephalopathy?
- CQ4-14. Is zinc preparation useful for hepatic encephalopathy?
- CQ4-15. Is carnitine supplementation useful for hepatic encephalopathy?
- CQ4-16. Are probiotics useful for hepatic encephalopathy?
- Portal vein thrombosis (PVT)
- BQ4-15. What is the pathogenesis and prognosis of PVT associated with cirrhosis?
- CQ4-17. What is an effective treatment for PVT associated with cirrhosis?
- Sarcopenia
- CQ4-18. Does sarcopenia affect the prognosis of cirrhotic patients?
- CQ4-19. Is there a useful treatment for sarcopenia associated with cirrhosis?
- Muscle cramps
- CQ4-20. Is there a useful treatment for muscle cramps associated with cirrhosis?
- Others
- CQ4-21. Is thrombopoietin receptor agonist effective for thrombocytopenia in patients with liver cirrhosis?
- CQ4-22. Is the oral anti-pruritus agent, nalfurafine hydrochloride, effective for pruritus in patients with chronic liver disease?
- FRQ4-5: Are splenectomy and partial splenic embolization (PSE) effective for the improvement in the pathophysiology of liver cirrhosis?
- FRQ4-6. What is hepato-pulmonary syndrome (HPS)?
- FRQ4-7. What is portopulmonary hypertension (PoPH)?
- FRQ4-8. Does vitamin D deficiency affect the pathophysiology and prognosis of patients with cirrhosis?
- Predicting prognosis
- BQ5-1. Are Child-Pugh classification and MELD score (MELD-Na score) useful for predicting the prognosis of patients with liver cirrhosis?
- CQ5-1. What are the useful factors for predicting the prognosis in patients with cirrhosis except for Child-Pugh classification and MELD score (MELD-Na score)?
- Liver transplant
- BQ6-01. Does liver transplantation improve the survival of patients with decompensated cirrhosis?
- CQ6-1. Is antiviral therapy useful in controlling HBV infection after liver transplantation?
- CQ6-2. Should we use antiviral therapy before and after liver transplantation for patients with type C cirrhosis?
- CQ6-3. Is liver transplantation useful for non-viral liver cirrhosis?
- Appendix
- Creation Committee
- Evaluation Committee
- The Japanese Society of Gastroenterology
- The Japan Society of Hepatology
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