Neurological Examination and Treatment for Hepatic Encephalopathy in Deep Jaundice
For patients with deep jaundice suspected of having hepatic encephalopathy, a comprehensive neurological assessment should include both clinical examination and specialized testing such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) or PSE-Syndrom-Test, with treatment focused on ammonia-lowering therapies including lactulose and rifaximin. 1, 2
Clinical Neurological Examination
- Assess level of consciousness and orientation status using the West Haven Criteria (grades 0-4) for overt hepatic encephalopathy, or Glasgow Coma Scale for patients with significantly altered consciousness 2
- Check for presence of asterixis (flapping tremor), a key clinical sign of hepatic encephalopathy 3
- Perform a complete neurological examination including cognitive, motor, sensory, neurovisual and cranial nerve testing 2
- Evaluate for specific cognitive deficits in attention, visuospatial abilities, fine motor skills, and memory, which are commonly impaired in hepatic encephalopathy 1
- Conduct the Animal Naming Test as a simple screening tool (patient lists as many animal names as possible in 1 minute; fewer than 20 names suggests covert hepatic encephalopathy) 2
Laboratory and Imaging Assessment
- Measure blood ammonia levels, recognizing that proper collection technique is essential (fasting patient, avoiding venous stasis, collecting in EDTA tube, placing immediately on ice) 2, 4
- Obtain complete blood count, comprehensive metabolic panel, coagulation profile, and electrolytes to assess disease severity and identify precipitating factors 4
- Perform brain imaging (preferably MRI) to exclude other causes of altered mental status, especially during the first episode of hepatic encephalopathy 2
- Consider electroencephalogram (EEG) or evoked potentials for objective assessment of brain function, particularly in patients with covert hepatic encephalopathy 1, 2
Specialized Testing for Covert/Minimal Hepatic Encephalopathy
- Use validated neuropsychological test batteries that measure multiple cognitive domains, as these are more reliable than single tests and correlate better with functional status 1
- Implement either the RBANS or PSE-Syndrom-Test, which have met psychometric and clinical validity criteria for assessing minimal hepatic encephalopathy 1
- Consider using computerized tests such as Critical Flicker Frequency or reaction time tests as complementary assessment tools 2
- For research purposes or multicenter studies, use at least two validated testing strategies 2
Treatment Approach
- Identify and treat precipitating factors, which is crucial for managing episodic hepatic encephalopathy 5
- Initiate lactulose therapy (oral and/or enemas) as first-line treatment to reduce blood ammonia levels by 25-50%, which typically correlates with improvement in mental status 6, 7
- Add rifaximin 550 mg twice daily for patients with recurrent episodes or those not responding adequately to lactulose alone 3, 5
- Continue lactulose for secondary prophylaxis, adding rifaximin for recurrent hepatic encephalopathy 5
- Monitor treatment response through clinical assessment and, when appropriate, repeat neuropsychological testing 7
Special Considerations and Pitfalls
- Differentiate hepatic encephalopathy from other causes of altered mental status, including hydroelectrolytic disorders, drug-induced conditions, Wernicke-Korsakoff syndrome, and psychiatric disorders 2
- Recognize that a normal ammonia level does not exclude hepatic encephalopathy and requires diagnostic reevaluation 2
- Be aware that minimal/covert hepatic encephalopathy significantly impacts quality of life, predicts development of overt encephalopathy, and may be associated with poorer prognosis 8
- Consider that patients with minimal hepatic encephalopathy may have normal standard mental status testing but still have significant cognitive impairments detectable only through specialized testing 1, 8
- For patients with fulminant hepatic failure and severe encephalopathy, consider transfer to a transplant center and intensive care unit admission with measures to reduce cerebral edema 9