What is the immediate treatment for hepatic encephalopathy in an emergency?

Immediate Treatment of Hepatic Encephalopathy in the Emergency Setting

Start lactulose immediately at 30-45 mL (20-30 g) every 1-2 hours orally or via nasogastric tube until the patient has at least 2 bowel movements per day, while simultaneously identifying and treating precipitating factors. 1, 2, 3

Initial Stabilization and Airway Management

• Intubate immediately for airway protection if the patient has grade III-IV encephalopathy (West Haven criteria), as these patients cannot protect their airway and are at high risk for aspiration 4
• Elevate the head of bed to 30 degrees to reduce intracranial pressure 4, 5
• Provide intensive care monitoring for patients with higher grades of hepatic encephalopathy 2

Identify and Treat Precipitating Factors (Critical Step)

This step treats nearly 90% of patients and is of paramount importance. 2 The precipitating factor can be identified in 80-90% of cases, and hepatic encephalopathy often improves simply by eliminating it. 1

Systematic evaluation for common triggers:

• Gastrointestinal bleeding: Perform endoscopy, complete blood count, digital rectal examination, stool blood test; treat with transfusion, endoscopic therapy, or vasoactive drugs 1
• Infection: Check complete blood count with differential, C-reactive protein, chest X-ray, urinalysis with culture, blood culture, diagnostic paracentesis if ascites present; initiate antibiotics 1
• Constipation: Obtain history and abdominal X-ray; treat with enema or laxatives 1
• Dehydration/renal dysfunction: Assess skin elasticity, blood pressure, pulse; stop or reduce diuretics and provide fluid therapy with intravenous albumin 1
• Electrolyte disturbances: Check serum sodium and potassium; adjust diuretics and provide appropriate replacement 1
• Medications: Review for benzodiazepines (give flumazenil if needed) or opioids (give naloxone if needed) 1

First-Line Pharmacological Treatment: Lactulose

For patients who can take oral medications or have nasogastric tube:

• Administer 30-45 mL of lactulose every 1-2 hours until rapid laxation is achieved (initial phase) 1, 3
• Once laxative effect is achieved, reduce to maintenance dosing of 30-45 mL three to four times daily 3
• Titrate dose to produce 2-3 soft stools per day 1, 2, 3
• Improvement may occur within 24 hours but may take up to 48 hours or longer 3

For patients with severe hepatic encephalopathy (grade 3-4) who cannot take oral medications:

• Administer lactulose enema: Mix 300 mL lactulose with 700 mL water or physiologic saline 1, 3
• Retain enema for at least 30-60 minutes 1, 3
• Repeat every 4-6 hours until clinical improvement 1, 3
• Do not use soap suds or alkaline cleansing enemas 3
• Start oral lactulose before stopping enema therapy entirely 3

Critical pitfall: Overuse of lactulose can paradoxically precipitate hepatic encephalopathy through excessive diarrhea causing dehydration and electrolyte disturbances. 2

Add-On Therapy for Non-Responders

• Rifaximin can be added for patients not responding adequately to lactulose alone, though this is typically used after initial stabilization 2, 6
• Consider IV L-Ornithine L-Aspartate (LOLA) or oral branched-chain amino acids as alternatives for refractory cases 2

Management of Agitation

If severe agitation develops:

• Use haloperidol 0.5-5 mg PO/IM every 8-12 hours for mild to moderate agitation 4
• Avoid benzodiazepines as they have delayed clearance in liver failure and worsen encephalopathy 4
• If sedation is absolutely necessary, use propofol in small doses as it may reduce cerebral blood flow 4

Management of Seizures

• Treat seizures with phenytoin as first-line, not sedation 4, 5
• Benzodiazepines should only be used in minimal doses if absolutely necessary due to delayed clearance 5
• Seizures may indicate intracranial hypertension requiring mannitol (0.5-1 g/kg bolus) 4

Nutritional Considerations

• Do not restrict protein intake in cirrhotic patients with hepatic encephalopathy as it increases protein catabolism 1
• In patients with severe hyper-acute disease and highly elevated arterial ammonia (>150 mMol/L) at risk for cerebral edema, protein support can be deferred for 24-48 hours only, with arterial ammonia monitoring 1
• Patients with mild hepatic encephalopathy can be fed orally as long as cough and swallow reflexes are intact 1

Critical Monitoring

• Perform frequent neurological evaluations for signs of intracranial hypertension 4
• Monitor hemodynamic parameters, renal function, glucose, and electrolytes 4
• Venous blood ammonia levels are not proportional to the degree of hepatic encephalopathy and are not associated with prognosis, but normal ammonia in suspected hepatic encephalopathy requires differentiation from other diseases 1

Common Pitfalls to Avoid

• Failure to identify precipitating factors leads to poor treatment response and is the most common error 2
• Delaying treatment while awaiting diagnostic confirmation worsens outcomes 2
• Using benzodiazepines for agitation or sedation interferes with neurological assessment and worsens encephalopathy 4
• Restricting protein intake increases catabolism and should be avoided 1