How can the risk of hepatic (liver) encephalopathy be managed?

Managing the Risk of Hepatic Encephalopathy

The risk of hepatic encephalopathy can be effectively managed through systematic screening, identification and treatment of precipitating factors, and appropriate pharmacological interventions including lactulose as first-line therapy and rifaximin for recurrent episodes.

Screening and Diagnosis

• All patients with cirrhosis should be systematically screened for both overt and covert hepatic encephalopathy (HE), regardless of liver function status 1
• The animal naming test is recommended as a simple, rapid bedside screening tool that can be performed by physicians, nurses, and caregivers in just 60 seconds 1
• Alternative or additional causes of neuropsychiatric impairment should be identified to improve prognostic accuracy and treatment results 1
• Diagnostic workup should include blood tests for glucose, electrolytes, inflammatory markers, full blood count, blood alcohol level, ammonia, thyroid-stimulating hormone, and brain imaging when appropriate 1

Identification and Management of Precipitating Factors

• Nearly 90% of patients can be treated solely by correcting precipitating factors 2
• Common precipitating factors that must be addressed include:
  • Infections (urinary tract infections, pneumonia) 2
  • Gastrointestinal bleeding 2
  • Electrolyte disturbances, particularly hyponatremia (<130 mmol/L) 2, 3
  • Medication non-compliance 2
  • Constipation 2
  • Proton pump inhibitors (PPIs), which should be restricted to strict validated indications 1, 2
  • Benzodiazepines, which are contraindicated in decompensated liver cirrhosis 2

Pharmacological Treatment

• Lactulose is recommended as first-line therapy for both acute overt HE and prevention of recurrence 2, 4

  • Dosage: 25 ml lactulose syrup every 12 hours, titrated to achieve 2-3 soft stools per day 2
  • Controlled studies have shown that lactulose reduces blood ammonia levels by 25-50%, which parallels improvement in mental state 4

• Rifaximin (550 mg twice daily) should be added when:

  • The patient's condition does not improve with lactulose alone 2
  • For prevention of recurrent episodes after a second episode of HE 2, 5
  • In clinical trials of rifaximin for HE, 91% of patients were using lactulose concomitantly 5

Prevention of Recurrence

• Secondary prophylaxis is recommended after an episode of HE using lactulose, with rifaximin added for recurrent encephalopathy 2, 1
• Managing complications of cirrhosis (e.g., spontaneous bacterial peritonitis, GI bleeding) according to available guidelines is essential 1
• Monitoring of sodium levels is recommended in patients with decompensated liver cirrhosis, as severe hyponatremia is a predisposing factor for HE 2, 3
• Nutritional support is critical as weight loss with sarcopenia may worsen HE 1
  • Provide enough protein and energy to favor positive nitrogen balance and increase muscle mass 1

Special Considerations

• Patients with higher grades of encephalopathy who cannot protect their airways require intensive monitoring and should be treated in an intensive care unit 2
• The head of the patient should be elevated by 30 degrees to reduce intracranial pressure 2
• Intubation is recommended for patients with Grade III-IV HE to protect the airways 2
• Sedatives should be avoided whenever possible, as they can impair neurological assessment 2
• Occlusion of a dominant portosystemic shunt may improve HE in patients with recurring HE and good liver function, though experience is limited 1

Long-term Management and Follow-up

• Patient and caregiver education should include:

  • Effects of medication and potential side effects 1
  • Importance of treatment adherence 1
  • Early signs of recurring HE 1
  • Actions to take if recurrence occurs 1

• Monitoring neurological manifestations is necessary to:

  • Adjust treatment in patients with persisting HE 1
  • Investigate the presence and degree of covert HE or signs of recurring HE 1
  • Evaluate gait and walking to consider the risk of falls 1

• Recurrent, treatment-refractory HE combined with liver failure is an indication for liver transplantation 2

  • Liver transplantation leads to significant improvement in most cognitive functions in patients with HE 2, 3
  • A neurological examination should be performed before transplantation 2

Treatment Endpoints

• Treatment endpoints should cover two key aspects:
  • Cognitive performance (improvement in at least one accepted test) 1
  • Daily life autonomy (basic and operational abilities) 1