What is the management of hepatic encephalopathy?

Management of Hepatic Encephalopathy

The management of hepatic encephalopathy should focus on identifying and correcting precipitating factors, initiating treatment with lactulose as first-line therapy, and adding rifaximin for recurrent episodes. 1, 2

Diagnosis and Initial Assessment

• Measure plasma ammonia levels in patients with suspected hepatic encephalopathy, as a normal value brings the diagnosis into question and should prompt investigation for alternative causes 3
• Perform brain imaging to exclude structural lesions in patients with unexplained alteration of brain function 3
• Systematically evaluate for signs of hepatic encephalopathy including asterixis, psychomotor slowing, sleep-wake inversion, and temporospatial disorientation 1
• Classify the severity using the grading system (I-IV) to guide management decisions:
  • Grade I: Mild alterations in consciousness, subtle personality changes
  • Grade II: Disorientation, lethargy, inappropriate behavior
  • Grade III: Marked confusion, sleeping but arousable
  • Grade IV: Comatose, unresponsive 3

Treatment Algorithm

Step 1: Identify and Correct Precipitating Factors

• Address precipitating factors, which are present in approximately 50% of cases and lead to improvement in 90% of cases when corrected 3
• Common precipitating factors include:
  • Infections
  • Gastrointestinal bleeding
  • Constipation
  • Dehydration
  • Electrolyte disturbances (especially hyponatremia)
  • Medications (sedatives, benzodiazepines)
  • Renal dysfunction 3

Step 2: Pharmacological Management

• First-line treatment: Lactulose

  • Initial dose: 25 ml orally every 12 hours, titrated to achieve 2-3 soft stools per day 2, 4
  • Mechanism: Reduces blood ammonia levels by 25-50% through acidification of the gastrointestinal tract 4
  • Clinical response observed in approximately 75% of patients 4

• Second-line/Add-on treatment: Rifaximin

  • Indicated for reduction in risk of overt hepatic encephalopathy recurrence 5
  • Dosage: 550 mg orally twice daily 5
  • Add rifaximin when lactulose alone fails to prevent recurrence 2
  • Reduces risk of recurrence by 58% when added to lactulose 2

Step 3: Level of Care Based on Severity

• Grades I-II: Can be managed on a general medical ward 1
• Grades III-IV: Require ICU admission with the following considerations:
  • Intubate for airway protection 3
  • Consider propofol for sedation if needed (may reduce cerebral blood flow) 3
  • Position head elevated at 30 degrees 3
  • Avoid stimulation and maneuvers that cause straining 3
  • Control seizures with phenytoin if present 3

Special Considerations

Monitoring and Prevention

• Monitor sodium levels closely, as hyponatremia is an independent risk factor for hepatic encephalopathy with a critical threshold of 130 mmol/L 3
• Avoid unnecessary use of proton pump inhibitors, which increase the risk of hepatic encephalopathy by promoting intestinal dysbiosis 3
• Contraindicate benzodiazepines in patients with decompensated cirrhosis 3
• Continue secondary prophylaxis with lactulose after the first episode of overt hepatic encephalopathy 3

Long-term Management

• Consider liver transplantation evaluation for patients with recurrent or intractable hepatic encephalopathy 3, 2
• Provide education to patients and caregivers about:
  • Medication effects and potential side effects
  • Importance of adherence
  • Early signs of recurring hepatic encephalopathy
  • Actions to take if recurrence occurs 3

Common Pitfalls to Avoid

• Relying solely on ammonia levels for diagnosis or treatment monitoring 1, 2
• Excessive use of lactulose leading to complications such as aspiration, dehydration, and hypernatremia 2
• Failing to recognize and address precipitating factors 1, 2
• Using rifaximin as monotherapy for initial treatment of overt hepatic encephalopathy 2
• Not considering secondary prophylaxis after the first episode 3