Gut microbiota dysbiosis in chronic liver disease: Mechanisms driving hepatocellular carcinoma progression and therapeutic implications of Chinese medicine

Chronic liver disease represents a major global public health challenge, and its malignant progression to hepatocellular carcinoma is the leading cause of death among affected patients. Gut microbiota dysbiosis is a critical driver of this process. As the central hub of the “gut–liver axis,” the gut microbiota, when disrupted, compromises the integrity of the intestinal mucosal barrier, promoting the translocation of microbial metabolites, such as lipopolysaccharides and aberrant secondary bile acids, to the liver. In turn, key signaling pathways become activated, including TLR4/NF-κB, Wnt/β-catenin, and PI3K/Akt, sustaining persistent hepatic inflammation and oxidative stress. These pathological processes accelerate the progression from liver fibrosis to cirrhosis, promote genomic instability, and suppress tumor suppressor gene expression, paving the way for the malignant transformation of hepatocytes. Leveraging its holistic regulatory properties, characterized by multi-component, multi-target, and multi-pathway actions, Chinese medicine can intervene at multiple stages of this inflammation-to-cancer cascade by modulating both the structure and function of the gut microbiota. It does so first by enriching beneficial short-chain fatty acid–producing bacteria, such as Lactobacillus and members of the phylum Firmicutes , which helps restore the intestinal mucosal barrier, limit endotoxin translocation, and alleviate hepatic inflammation and fibrosis. In parallel, by normalizing bile acid metabolism and reestablishing gut microbial homeostasis, Chinese medicine counteracts the development of a tumor-permissive microenvironment marked by immune suppression and DNA damage in hepatocytes induced by microbial metabolites. At the same time, it enhances anti-tumor immune responses mediated by CD8 + T cells and other immune effectors. Drawing on evidence from multi-omics analyses and clinical studies, this review examines the core mechanisms and recent advances regarding how Chinese medicine monomers and formulations modulate the gut microbiota to impede the progression of chronic liver disease to HCC. It highlights gut microbiota dysbiosis as a key driver of hepatocarcinogenesis and highlights the therapeutic potential of targeted microbiota regulation by Chinese medicine, providing a conceptual foundation and strategic approaches for the precision prevention and treatment of hepatocellular carcinoma.