What is the risk of hepatic encephalopathy (HE) in obstructive jaundice?

Risk of Hepatic Encephalopathy in Obstructive Jaundice

Obstructive jaundice does not typically cause hepatic encephalopathy unless there are complications or advanced liver disease, as hepatic encephalopathy primarily occurs in the setting of cirrhosis with portal hypertension or significant portosystemic shunting. 1

Pathophysiology and Risk Factors

• Hepatic encephalopathy (HE) occurs primarily in patients with cirrhosis or portosystemic shunts, not typically in isolated obstructive jaundice 1, 2
• The risk increases if obstructive jaundice leads to:
  • Secondary biliary cirrhosis with portal hypertension development 1
  • Significant liver dysfunction with reduced ability to clear ammonia 2
  • Development of portosystemic shunts 1

Clinical Presentation and Diagnosis

• In patients with obstructive jaundice who develop HE, the presentation ranges from subtle cognitive changes (covert HE) to more obvious neurological dysfunction (overt HE) 1, 3
• Covert HE affects 30-70% of patients with cirrhosis and is associated with:
  • Reduced quality of life
  • Impaired socio-economic potential
  • Increased risk of developing overt HE 1
• Diagnostic approaches for HE in the setting of obstructive jaundice:
  • Animal Naming Test (listing animals in 60 seconds) is recommended as a bedside screening tool 1
  • No cerebral imaging technique definitively proves HE diagnosis 1
  • Blood ammonia levels should be measured but are not diagnostic alone 1

Management Considerations

• Treatment should focus on addressing the underlying obstructive cause while managing any HE symptoms 1
• For patients who develop HE:
  • Non-absorbable disaccharides (lactulose) are first-line treatment for both acute overt HE and prevention 1
  • Rifaximin (550 mg twice daily) should be added to lactulose for prevention of recurrent episodes after a second episode 1, 4
  • Identify and treat precipitating factors, which is crucial as nearly 90% of patients improve with correction of precipitating factors alone 5

Special Considerations

• Patients with obstructive jaundice undergoing TIPS (transjugular intrahepatic portosystemic shunt) have increased risk of developing HE 1
• Routine prophylactic therapy with lactulose or rifaximin is not recommended for post-TIPS HE prevention 1
• Patients with covert HE should be treated with non-absorbable disaccharides to prevent progression to overt HE 1

Monitoring and Follow-up

• After resolution of obstructive jaundice, patients should be monitored for:
  • Neurological manifestations to adjust treatment 1
  • Signs of recurring HE 1
  • Risk of falls due to potential gait and walking impairment 1

Prognosis

• HE significantly impacts quality of life and increases mortality risk 6, 2
• Liver transplantation leads to significant improvement in most cognitive functions in patients with HE, with improvements beginning around 6 months post-transplant 1
• The presence of HE in patients with equivalent MELD scores significantly increases short and medium-term risk of death by 2-4 times compared to patients without HE 1