From the Guidelines
Hepatic encephalopathy should be treated as a continuum ranging from unimpaired cognitive function with intact consciousness through coma, and patients with overt HE grade 3 and 4 are at risk of aspiration and should be treated in the ICU 1.
Diagnosis and Grading
The diagnosis of hepatic encephalopathy (HE) is through exclusion of other causes of brain dysfunction, and it should be divided into various stages of severity, reflecting the degree of self-sufficiency and the need for care 1.
- Overt HE is diagnosed by clinical criteria and can be graded according to the West Haven criteria (WHC) and the Glasgow Coma Scale (GCS) 1.
- The West Haven criteria should be used for HE grading when at least temporal disorientation is present, and in patients with no or mild neuropsychiatric abnormalities, a neuropsychological/neurophysiological or therapeutic test should be used to diagnose covert HE 1.
Treatment
- Lactulose is recommended as secondary prophylaxis following a first episode of overt HE, and should be titrated to obtain 2-3 bowel movements per day 1.
- Rifaximin as an adjunct to lactulose is recommended as secondary prophylaxis following more than one additional episode of overt HE within 6 months of the first one 1.
- In patients presenting with gastrointestinal bleeding, rapid removal of blood from the gastrointestinal tract can be used to prevent HE 1.
Management
- Patients with recurrent or persistent HE should be considered for liver transplantation, and a first episode of overt HE should prompt referral to a transplant centre for evaluation 1.
- All measures to control progression of the underlying liver disease should be undertaken, and precipitating factors should be sought and managed 1.
- Brain imaging by CT scan or MRI should be performed in case of diagnostic doubts or non-response to treatment, and plasma ammonia measurement should be performed as a normal value brings the diagnosis of HE into question 1.
From the Research
Treatment of Hepatic Encephalopathy
- The treatment of hepatic encephalopathy (HE) involves a combination of general and specific measures, including tracheal intubation, nasogastric tube placement, and avoidance of sedatives 2.
- Correction of the precipitating factor is the most important measure in treating HE 2.
- Lactulose is a key medication used in the treatment of HE, and can be administered via enema or nasogastric tube in deep encephalopathy 2.
- Rifaximin is another medication that has been shown to be effective in combination with lactulose for the treatment of overt HE 3, 4, 5.
Combination Therapy
- Combination therapy with rifaximin and lactulose has been shown to be more effective than lactulose alone in the treatment of overt HE 4, 5.
- A systematic review and meta-analysis found that the use of rifaximin plus lactulose was associated with an increased incidence of effective rate and reduced risk of mortality compared to lactulose alone 4.
- However, another study found that lactulose only was more effective than lactulose and rifaximin in improving neurological status and reducing mortality 3.
Prevention of Hepatic Encephalopathy
- The combination of rifaximin and lactulose may be considered for the prevention of HE, especially after the second episode of HE recurrence 6.
- Probiotics and other medications, such as metronidazole and neomycin, have also been studied as potential treatments for HE, but more research is needed to determine their effectiveness 6.
Nutrition and Lifestyle
- Nutrition plays an important role in the management of HE, and patients should be advised to follow a diet that is high in protein and low in salt 2.
- Patients with HE should also avoid alcohol and other substances that can exacerbate the condition 2.
- Regular follow-up with a healthcare provider is important to monitor the progression of HE and adjust treatment as needed 2.