From the Guidelines
Hepatic encephalopathy should be treated as a continuum ranging from unimpaired cognitive function with intact consciousness through coma, and lactulose is recommended as secondary prophylaxis following a first episode of overt HE, titrated to obtain 2-3 bowel movements per day 1. 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.
Key Considerations
- Overt HE is diagnosed by clinical criteria and can be graded according to the West Haven criteria and the Glasgow Coma Scale (GCS) 1.
- The diagnosis and grading of minimal hepatic encephalopathy (MHE) and covert HE (CHE) can be made using several neurophysiological and psychometric tests that should be performed by experienced examiners 1.
- Increased blood ammonia alone does not add any diagnostic, staging, or prognostic value for HE in patients with chronic liver disease (CLD), and a normal value calls for diagnostic reevaluation 1.
- Patients with HE should not be classified based on the etiology of their underlying liver disease, and alternative or additional causes of neuropsychiatric impairment should be identified to improve prognostic accuracy and the results of treatment 1.
Management
- 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 (lactulose or mannitol by nasogastric tube or lactulose enemas) can be used to prevent HE 1.
- 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 center for evaluation 1.
From the Research
Hepatic Encephalopathy Treatment
- Hepatic encephalopathy (HE) is a serious complication of liver disease, and its treatment is primarily focused on reducing blood ammonia levels 2, 3, 4, 5.
- Lactulose and rifaximin are commonly used in the treatment of HE, with studies showing that their combination is more effective than lactulose alone in some cases 2, 6, 3.
- However, the study by 6 found that patients treated with lactulose only had better outcomes than those treated with lactulose and rifaximin, suggesting that lactulose may be a sufficient first-line treatment for overt HE.
- Branched-chain amino acids (BCAA) have also been shown to have beneficial effects on HE manifestations, and may be used in combination with non-absorbable disaccharides like lactulose 3, 4.
- Newer treatments, such as ornithine phenylacetate, spherical carbon, and fecal microbiota transplant, are being studied and may offer potential benefits for HE patients 4.
Pathophysiology and Diagnosis
- Hepatic encephalopathy is characterized by low-grade cerebral edema, oxidative/nitrosative stress, inflammation, and disturbances of oscillatory networks in the brain 5.
- Ammonia and inflammation are major triggers for the appearance of HE, and severity classification and diagnostic approaches are still a matter of debate 5.
- Current medical treatment involves lactulose and rifaximin, as well as rigorous treatment of known HE precipitating factors 5.
Treatment Outcomes
- The combination of lactulose and rifaximin has been shown to be more effective than lactulose alone in reducing mortality and hospital stay in some studies 2.
- However, the study by 6 found that patients treated with lactulose only had lower mortality and better improvement in neurological status than those treated with lactulose and rifaximin.
- The use of BCAA supplements has been shown to have beneficial effects on HE manifestations, and may be used in combination with non-absorbable disaccharides like lactulose 3, 4.