From the Guidelines
Correctable precipitating factors of hepatic encephalopathy include gastrointestinal bleeding, infection, constipation, excessive dietary protein intake, dehydration, electrolyte abnormalities, medication non-compliance, sedative use, and diuretic overuse, as identified in the most recent guidelines 1. The management of these factors is crucial in preventing and treating hepatic encephalopathy.
- Gastrointestinal bleeding requires endoscopic intervention and blood transfusions as necessary.
- Infections should be treated with appropriate antibiotics based on culture results.
- Constipation can be managed with lactulose 20-30g orally every 6-12 hours, titrated to achieve 2-3 soft bowel movements daily.
- Protein intake should be moderated to 1.0-1.5 g/kg/day rather than severely restricted.
- Dehydration requires careful fluid resuscitation with normal saline while monitoring for volume overload.
- Electrolyte imbalances, particularly hypokalemia, should be corrected with potassium supplementation.
- Medication adherence for existing hepatic encephalopathy treatments should be reinforced, especially lactulose and rifaximin 550mg twice daily.
- Sedatives, opioids, and benzodiazepines should be avoided or minimized.
- Diuretic doses may need adjustment if overdiuresis is contributing to encephalopathy. These factors are important to address because they increase ammonia production or decrease the body's ability to metabolize ammonia, which is the primary neurotoxin responsible for hepatic encephalopathy symptoms, as supported by recent guidelines 1 and previous studies 1. Prioritizing the treatment of precipitating factors and initiating treatment with a non-absorbable disaccharide, such as lactulose or lactitol, is recommended for cirrhotic patients with overt hepatic encephalopathy 1.
From the Research
Correctable Precipitating Factors of Hepatic Encephalopathy
The correctable precipitating factors of hepatic encephalopathy include:
- Infection, which was the most common precipitating factor in several studies 2, 3, 4, 5
- Electrolyte imbalance, such as hyponatremia and hypokalemia 2, 3, 4, 5
- Constipation 2, 3, 4
- Gastrointestinal bleeding 2, 3, 4, 5
- Use of diuretics 3
- Use of sedatives 3
- Excess intake of protein 3
- Non-adherence to ammonia-lowering therapy 5
- Drugs precipitating overt hepatic encephalopathy 5
Importance of Identifying Precipitating Factors
Identifying and controlling these precipitating factors is crucial in the management of hepatic encephalopathy, as they can significantly impact the prognosis and outcome of patients with cirrhosis 5. The presence of multiple concomitant precipitating factors is associated with a poor prognosis and increased risk of death or liver transplantation 5. Therefore, a systematic screening for all precipitating factors of hepatic encephalopathy should be proposed for cirrhotics admitted to intensive care unit 5.