From the Guidelines
Hepatic encephalopathy is traditionally classified into four grades (1-4) according to the West Haven Criteria, not five grades, and therefore, there is no such thing as grade 5 hepatic encephalopathy in standard medical classification systems. Hepatic encephalopathy represents a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction after exclusion of other brain diseases [ 1 ]. The grading system ranges from minimal (subclinical) to grade 4, which represents coma.
Key Points to Consider
- Grade 1 shows trivial lack of awareness and anxiety, grade 2 includes lethargy and disorientation, grade 3 involves somnolence and confusion, and grade 4 is characterized by coma [ 1 ].
- Treatment typically includes identifying and treating precipitating factors, reducing ammonia production through lactulose (15-30 mL orally 2-4 times daily, titrated to produce 2-3 soft bowel movements daily), adding rifaximin (550 mg twice daily), ensuring adequate protein intake (1.2-1.5 g/kg/day), and providing supportive care [ 1 ].
- In severe cases (grade 3-4), patients require ICU admission, airway protection, and more aggressive management of precipitating factors such as infections, gastrointestinal bleeding, electrolyte disturbances, or medication effects [ 1 ].
- The West Haven criteria should be used for HE grading when at least temporal disorientation is present (i.e. from West Haven grades >2), and in patients with grades III-IV West Haven criteria, the Glasgow coma scale should be added [ 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 centre for evaluation [ 1 ].
Management Considerations
- 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 >1 additional episodes 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 ].
From the Research
Hepatic Encephalopathy Grade 5
There is no direct mention of Hepatic Encephalopathy grade 5 in the provided studies. However, the studies discuss the classification and treatment of Hepatic Encephalopathy (HE) in general.
- The studies mention that HE is a serious neuropsychiatric complication of cirrhosis and/or porto-systemic shunting, with clinical symptoms ranging from subtle impairment in mental state to coma 2, 3, 4.
- The severity of HE is typically classified into different grades, but the exact grading system is not consistently defined across the studies 2, 3, 4.
- The treatment of HE typically involves reducing ammonia levels and inflammation, and may include medications such as lactulose and rifaximin 3, 4, 5.
- In severe cases of HE, more aggressive treatment may be necessary, including intensive care unit admission and liver transplantation 6, 3.
Treatment Options
The treatment options for HE are varied and depend on the severity of the condition. Some of the treatment options mentioned in the studies include:
- Lactulose and rifaximin to reduce ammonia levels and inflammation 3, 4, 5
- L-ornithine L-aspartate (LOLA) to stimulate the urea cycle and reduce ammonia levels 3
- Mannitol and ventilatory support to reduce cerebral edema 6, 3
- Liver transplantation in severe cases 6, 3
Pathophysiology
The pathophysiology of HE is complex and involves multiple factors, including:
- Disturbance of the urea cycle due to liver disease, leading to increased production of ammonia 3
- Increased cerebral oxidative/nitrosative stress and inflammation 3, 4
- Disrupted enterohepatic circulation and elevation of bile acids, leading to neuroinflammation 3
- Gut environment and intestinal flora playing a major role in brain function in patients with HE 3