What is the management of hepatic encephalopathy?

Management of Hepatic Encephalopathy

The first-line treatment for hepatic encephalopathy is lactulose, titrated to achieve 2-3 soft stools per day, with rifaximin recommended as second-line or add-on therapy for recurrent episodes. 1, 2

Diagnosis and Assessment

• Ammonia measurement cannot definitively diagnose hepatic encephalopathy, but a normal value casts doubt on the diagnosis 3
• Brain imaging should be performed only for differential diagnosis in patients with suspected hepatic encephalopathy, particularly during the first episode 3, 1
• The animal naming test can be used to detect covert hepatic encephalopathy, with a cut-off of 20 animal names in 1 minute 3, 2
• Severity of hepatic encephalopathy should be classified using a grading system (I-IV) to guide management decisions 1, 2

Treatment Algorithm

Step 1: Identify and Address Precipitating Factors

• Identifying and correcting precipitating factors is crucial, resolving up to 90% of cases 1, 2
• Common precipitating factors include:
  • Infections
  • Gastrointestinal bleeding
  • Constipation
  • Dehydration
  • Electrolyte disturbances
  • Medications (especially sedatives and benzodiazepines) 1, 2

Step 2: First-Line Pharmacological Treatment

• Lactulose is the first-line treatment for hepatic encephalopathy 1, 2, 4
• Initial dose: 25 ml orally every 12 hours 1
• Titrate dose to achieve 2-3 soft stools per day 1, 2
• Mechanism: Acidifies the gastrointestinal tract, inhibiting ammonia production by coliform bacteria 4, 5
• FDA-approved for treatment of portal-systemic encephalopathy 4

Step 3: Second-Line or Add-On Treatment

• Rifaximin is recommended as second-line or add-on treatment for patients with recurrent episodes despite lactulose use 1, 2, 6
• Dosage: 550 mg orally twice daily 1, 6
• FDA-approved for reduction in risk of overt hepatic encephalopathy recurrence 6
• In clinical trials, 91% of patients were using lactulose concomitantly 6
• Mechanism: Decreases intestinal production and absorption of ammonia by altering gastrointestinal flora 5

Step 4: Alternative Treatments

• Neomycin can be considered as an alternative antibiotic, but associated adverse events limit its use 7, 5
• FDA-approved as adjunctive therapy in hepatic coma by reducing ammonia-forming bacteria 7

Special Considerations

Monitoring and Follow-up

• Monitor sodium levels closely, as hyponatremia is an independent risk factor for hepatic encephalopathy 1
• Perform frequent mental status checks with transfer to ICU if level of consciousness declines 2
• Patients with grade III/IV encephalopathy require intubation for airway protection 8

Prevention of Recurrence

• Secondary prophylaxis with lactulose should be continued after the first episode of overt hepatic encephalopathy 1, 2
• Rifaximin is recommended as an adjunct to lactulose after recurrent episodes 2

Liver Transplantation

• Liver transplantation evaluation should be considered for patients with recurrent or intractable hepatic encephalopathy 1, 2

Common Pitfalls to Avoid

• Failing to seek precipitating factors, which cause 90% of cases 2
• Not titrating the lactulose dose adequately to achieve 2-3 stools per day 2
• Relying exclusively on ammonia levels for diagnosis 3, 2
• Using proton pump inhibitors, which increase the risk of hepatic encephalopathy 1
• Using benzodiazepines in patients with decompensated cirrhosis 1, 8
• Confusing hepatic encephalopathy with other causes of altered mental status 2