What is the management of hepatic encephalopathy?

Management of Hepatic Encephalopathy

The management of hepatic encephalopathy requires identifying and treating precipitating factors first, followed by lactulose as first-line therapy titrated to achieve 2-3 soft stools per day, with rifaximin added as second-line therapy 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 1
• Perform brain imaging to exclude structural lesions in patients with unexplained alteration of brain function 1
• Systematically evaluate for signs of hepatic encephalopathy, including asterixis, psychomotor slowing, sleep-wake inversion, and temporospatial disorientation 1, 2
• Classify severity using a grading system (I-IV) to guide management decisions:
  • Grade I: Mild alterations in consciousness
  • Grade II: Moderate disorientation and lethargy
  • Grade III: Marked confusion and somnolence
  • Grade IV: Comatose and unresponsive 1, 2

Treatment Algorithm

Step 1: Identify and Correct Precipitating Factors

• Precipitating factors are present in approximately 50% of cases and lead to improvement in 90% of cases when corrected 1, 2, 3
• Common precipitating factors include:
  • Infections
  • Gastrointestinal bleeding
  • Constipation
  • Dehydration
  • Electrolyte disturbances
  • Medications (especially sedatives and benzodiazepines) 1, 2

Step 2: First-Line Pharmacological Treatment

• Initiate lactulose without delay at a dose of 25 ml orally every 12 hours 1, 3, 4
• Titrate to achieve 2-3 soft stools per day 1, 2, 3
• Lactulose reduces blood ammonia levels by 25-50%, which generally parallels improvement in mental state 4
• Clinical response is observed in approximately 75% of patients 4

Step 3: Second-Line or Add-on Treatment

• Add rifaximin 550 mg orally twice daily when lactulose alone fails to prevent recurrence 1, 2, 3, 5
• Rifaximin reduces the risk of overt hepatic encephalopathy recurrence by 58% when added to lactulose 3, 5
• Rifaximin has been shown to improve quality of life and reduce hospital readmissions 3

Special Considerations

Monitoring and Follow-up

• Monitor sodium levels closely, as hyponatremia is an independent risk factor for hepatic encephalopathy with a critical threshold of 130 mmol/L 1
• Perform frequent mental status checks with transfer to an ICU if level of consciousness declines 2
• Monitor for metabolic abnormalities including glucose, potassium, magnesium, and phosphate levels 2

Prophylaxis

• Continue secondary prophylaxis with lactulose after the first episode of overt hepatic encephalopathy 1, 2, 3
• Consider rifaximin for long-term prophylaxis in patients with recurrent episodes despite lactulose use 2, 3

Advanced Management

• Consider liver transplantation evaluation for patients with recurrent or intractable hepatic encephalopathy 1, 2, 3
• Patients with grade III-IV encephalopathy require ICU admission for airway protection and closer monitoring 2, 3

Common Pitfalls to Avoid

• Avoid proton pump inhibitors due to increased risk of hepatic encephalopathy 1
• Contraindicate benzodiazepines in patients with decompensated cirrhosis 1, 2
• Do not rely exclusively on ammonia levels for diagnosis or monitoring 2, 3
• Avoid excessive use of lactulose that can lead to complications such as aspiration, dehydration, hypernatremia, and perianal skin irritation 3
• Do not use rifaximin as monotherapy for initial treatment of overt hepatic encephalopathy 3, 5
• Never fail to search for precipitating factors, which are present in most cases 1, 2, 3