From the Guidelines
Minimal hepatic encephalopathy (MHE) should be treated with lactulose, starting at 25-30 mL twice daily, and adjusted to achieve 2-3 soft bowel movements daily, as it impairs quality of life, affects daily functioning, and can progress to overt hepatic encephalopathy, as recommended by the most recent guidelines 1.
Key Considerations
- MHE is a subtle cognitive impairment found in patients with liver cirrhosis that affects attention, processing speed, and psychomotor abilities.
- Treatment with lactulose is the primary approach, with Rifaximin 550 mg twice daily added for patients who don't respond adequately to lactulose or cannot tolerate it.
- Addressing precipitating factors, such as avoiding sedatives, treating infections, correcting electrolyte imbalances, and managing gastrointestinal bleeding, is crucial.
- Dietary management includes limiting protein to 1.2-1.5 g/kg/day with emphasis on vegetable and dairy protein sources.
- Patients should be monitored with psychometric tests like the Number Connection Test or computerized assessments.
Rationale
The most recent guidelines from 2023 1 emphasize the importance of treating MHE to improve quality of life and prevent progression to overt hepatic encephalopathy. Lactulose is the recommended initial treatment, with Rifaximin added as needed. The guidelines also highlight the importance of addressing precipitating factors and managing dietary protein intake. By following these recommendations, clinicians can provide effective care for patients with MHE and improve their outcomes.
Additional Recommendations
- Patients with MHE should be referred to expert centers for consideration for liver transplantation if necessary, as recommended by the French guidelines 1.
- Clinicians should be aware of the potential for MHE to progress to overt hepatic encephalopathy and monitor patients closely for signs of worsening cognitive impairment.
From the Research
Definition and Prevalence of Minimal Hepatic Encephalopathy
- Minimal hepatic encephalopathy (MHE) is a condition characterized by neuropsychiatric and neurophysiological defects in patients with cirrhosis of the liver, despite normal mental and neurological status on standard clinical examination 2.
- The prevalence of MHE varies up to 80% in cirrhotic patients 2.
Characteristics and Features of Minimal Hepatic Encephalopathy
- MHE is characterized by a specific, complex cognitive dysfunction that is independent of sleep dysfunction or problems with overall intelligence 2.
- Key features of MHE include psychomotor slowing, visuoconstructive disabilities, attention deficits, and impaired fine motor performance 2.
Diagnosis and Treatment of Minimal Hepatic Encephalopathy
- Various tools have been evaluated for the correct diagnosis of MHE, but a combination of test methods is recommended in the absence of a "gold standard" 2.
- Lactulose is the mainstay of treatment for MHE, but other therapies like probiotics and ornithine aspartate are being evaluated as alternatives 2.
- Rifaximin and lactulose are widely used in patients with hepatic encephalopathy, and combination therapy with both drugs has been shown to be effective in reducing mortality and improving treatment outcomes 3, 4.
Long-term Management of Hepatic Encephalopathy
- Long-term management of hepatic encephalopathy with lactulose and/or rifaximin has been shown to be effective in preventing overt HE recurrence and reducing healthcare resource utilization 5.
- The addition of rifaximin to lactulose therapy has been shown to significantly reduce the risk of overt HE recurrence and HE-related hospitalization, compared with lactulose therapy alone 5.