What is the recommended management for hepatic encephalopathy?

Management of Hepatic Encephalopathy

The recommended first-line treatment for hepatic encephalopathy is lactulose, with rifaximin as adjunctive therapy for recurrent episodes, alongside identification and correction of precipitating factors. 1

Diagnosis and Classification

• Overt hepatic encephalopathy (OHE) is diagnosed by clinical criteria and can be graded according to the West Haven Criteria (WHC) and Glasgow Coma Scale (GCS) 2
• Normal ammonia levels call for diagnostic reevaluation 2, 1
• Alternative causes of altered mental status should be ruled out using brain imaging in cases of diagnostic uncertainty 1

West Haven Criteria:

• Grade I: Minimal changes in behavior, minimal changes in consciousness
• Grade II: Gross disorientation, drowsiness, inappropriate behavior, asterixis
• Grade III: Marked confusion, incoherent speech, sleeping most of time but arousable
• Grade IV: Comatose, unresponsive to pain, decerebrate posturing 1

Four-Pronged Approach to Management

1. Initiate appropriate care based on consciousness level

   • Patients with higher grades of HE who cannot protect their airway need intensive care monitoring 2, 1

2. Identify and treat alternative causes of altered mental status

   • Rule out other causes of encephalopathy with appropriate testing 2

3. Identify and correct precipitating factors

   • Nearly 90% of patients can be treated with just correction of precipitating factors 2, 1
   • Common precipitating factors:
     • Gastrointestinal bleeding
     • Infection/sepsis
     • Constipation
     • Electrolyte disturbances (especially hyponatremia)
     • Dehydration
     • Medication non-compliance
     • Excessive protein intake
     • Sedatives or tranquilizers 1
   • Monitor blood sodium levels (maintain >130 mmol/L, ideally >135 mmol/L) 2
   • Limit proton pump inhibitors to strict validated indications 2
   • Avoid benzodiazepines in patients with decompensated cirrhosis 2

4. Commence empirical HE treatment

Pharmacological Treatment

• Lactulose (first-line):

  • Dosage: 25 mL (17g) orally every 12 hours, adjusted to achieve 2-3 soft stools per day 1, 3
  • For patients unable to take oral medications: lactulose enemas (300 mL in 700 mL water) 1, 4
  • Caution: Excessive lactulose can lead to dehydration, hypernatremia, and perianal skin irritation 1

• Rifaximin (second-line/adjunctive):

  • Add rifaximin 550 mg twice daily after a second episode of HE within 6 months 1, 5
  • In clinical trials, 91% of patients were using lactulose concomitantly with rifaximin 5

Prevention and Secondary Prophylaxis

• Secondary prophylaxis after an episode of overt HE is strongly recommended 2
• Lactulose is effective for prevention of HE recurrence in patients with cirrhosis 6
• Primary prophylaxis is not required except in patients with cirrhosis at high risk for developing HE 2
• Maintain protein intake at 1.2-1.5 g/kg/day; protein restriction should be avoided 1
• Consider small, frequent meals throughout the day and a snack before bedtime 1

Liver Transplantation

• Recurrent intractable OHE, together with liver failure, is an indication for liver transplantation 2, 1
• The first episode of overt HE should prompt referral to a transplant center for evaluation 1

Monitoring and Follow-up

• Regular assessment of mental status to monitor response to treatment
• Evaluate stool frequency to adjust lactulose dosage
• Consider brain imaging (CT/MRI) in cases of diagnostic doubt or lack of response to treatment 1

Special Considerations

• Minimal hepatic encephalopathy (MHE) and covert HE (CHE) are not routinely treated unless they affect quality of life, driving skills, work performance, or cognitive function 2
• Testing for MHE and CHE should be used in patients who would most benefit from testing 2
• Patients with non-cirrhotic portal hypertension can also develop HE, particularly with large portosystemic shunts 7