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Last reviewed: 13 Jan 2026
Last updated: 12 Feb 2026

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • older age
  • hepatomegaly
Full details

Other diagnostic factors

  • abdominal distension
  • oesophageal or gastric variceal bleeding
  • right upper quadrant abdominal pain
  • early satiety
  • weight loss
  • lower extremity oedema
  • hepatic encephalopathy
  • cachexia
  • jaundice
  • splenomegaly
  • asterixis
  • spider naevi
  • palmar erythema
  • periumbilical collateral veins
  • fetor hepaticus
  • diarrhoea
  • paraneoplastic syndrome
  • bone pain
  • severe abdominal pain
  • obstructive jaundice
  • enlarged haemorrhoidal veins
  • vascular bruit
Full details

Risk factors

  • cirrhosis
  • chronic hepatitis B (HBV) infection
  • chronic hepatitis C (HCV) infection
  • chronic heavy alcohol use
  • diabetes
  • obesity
  • family history of liver cancer
  • aflatoxin exposure
  • thorium dioxide radioactive contrast exposure
  • haemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cholangitis (PBC)
  • primary sclerosing cholangitis (PSC)
  • use of androgenic steroids
  • use of oral contraceptives
  • male sex
Full details

Diagnostic investigations

1st investigations to order

  • ultrasound of liver
  • FBC
  • basic metabolic panel
  • liver function tests
  • prothrombin time/INR
  • viral hepatitis panel
  • alpha fetoprotein (AFP)
Full details

Investigations to consider

  • contrast CT scan of abdomen
  • contrast MRI of abdomen
  • liver biopsy
  • CT scan of chest
  • bone scan
Full details

Treatment algorithm

ACUTE

Barcelona Clinic Liver Cancer (BCLC) stage 0-A (very early 0 or early disease A): possible surgical candidate (good liver function)

BCLC stage 0-A (very early 0 or early disease A): non-hepatic resection candidate

BCLC stage B: intermediate disease

BCLC stage C: advanced disease

BCLC stage D: end-stage disease

ONGOING

recurrence

Contributors

Authors

Doan Y Dao, MD

Assistant Professor of Medicine

Director, Center of Excellence for Liver Disease in Vietnam

Johns Hopkins School of Medicine

Department of Medicine

Division of GI & Hepatology

Baltimore

MD

Disclosures

DYD has received grant support from Roche Diagnostic International Ltd., Fujifilm Medical Systems, and DELFI Diagnostics LLC.

Ngoc Thai Truong, MD, MS

Research Assistant

Vietnam Viral Hepatitis Alliance

Reston

VA

Disclosures

NTT declares that he has no competing interests.

Acknowledgements

Dr Doan Y Dao and Dr Ngoc Thai Truong would like to gratefully acknowledge Dr Qingyao Daniel Huang, Dr Margaret Li Peng Teng, Dr Poh Seng Tan, Dr Badar Muneer, and Dr Smruti R. Mohanty, previous contributors to this topic.

Disclosures

QDH declares that he has no competing interests. MLPT declares that she has no competing interests. PST has received sponsorship/honorarium from Bayer (South East Asia) Pte Ltd and Sirtex for attending conferences, delivering lectures, and participating in advisory board meetings. BM declares that he has no competing interests. SRM serves as a speaker for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewers

Srikrishna Nagri, MD

Gastroenterologist

Dartmouth-Hitchcock Nashua

Nashua

NH

Disclosures

SN declares that he has no competing interests.

Ned Snyder, MD, FACP

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch

Galveston

TX

Disclosures

NS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: hepatocellular carcinoma [internet publication].Full text

Singal AG, Llovet JM, Yarchoan M, et al. AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology. 2023 Dec 1;78(6):1922-65.Full text

Vogel A, Chan SL, Dawson LA, et al. Hepatocellular carcinoma: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol. 2025 May;36(5):491-506.Full text

European Association for the Study of the Liver. EASL clinical practice guidelines on the management of hepatocellular carcinoma. J Hepatol. 2025 Feb;82(2):315-74.Full text  Abstract

Su GL, Altayar O, O'Shea R, et al. AGA clinical practice guideline on systemic therapy for hepatocellular carcinoma. Gastroenterology. 2022 Mar;162(3):920-34.Full text  Abstract

Gordan JD, Kennedy EB, Abou-Alfa GK, et al. Systemic therapy for advanced hepatocellular carcinoma: ASCO guideline update. J Clin Oncol. 2024 May 20;42(15):1830-50.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available here.

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