From the Guidelines
The most serious complications of hepatic encephalopathy include cerebral edema, coma, aspiration pneumonia, seizures, and long-term cognitive impairment, which can significantly impact morbidity, mortality, and quality of life. These complications can arise from the accumulation of neurotoxins like ammonia, leading to astrocyte swelling, altered neurotransmission, and neuronal dysfunction 1. The clinical presentation of hepatic encephalopathy can vary widely, ranging from mild cognitive impairments to severe neurological and psychiatric manifestations, including personality changes, disorientation, and motor function alterations 1.
Key Complications
- Cerebral edema, which can lead to increased intracranial pressure and potential brain herniation, particularly in acute liver failure
- Coma, representing an advanced complication where patients become unresponsive to stimuli, requiring intensive care support including mechanical ventilation
- Aspiration pneumonia, frequently occurring as diminished protective reflexes allow stomach contents to enter the lungs
- Seizures, which can be difficult to control and cause additional brain injury
- Long-term cognitive impairment, persisting even after recovery from acute episodes, affecting memory, attention, and executive function
Management
Management of hepatic encephalopathy focuses on treating the underlying liver disease, reducing ammonia production through medications such as lactulose and rifaximin, correcting precipitating factors, and providing supportive care including airway protection and hemodynamic support 1. The use of lactulose (15-30 ml orally 2-4 times daily) and rifaximin (550 mg twice daily) is recommended for reducing ammonia production and managing hepatic encephalopathy 1.
Recent Guidelines and Recommendations
Recent studies and guidelines emphasize the importance of early detection and management of hepatic encephalopathy, including the use of bedside tools for screening and the consideration of ammonia-lowering strategies and other therapeutic approaches 1. The classification and management of hepatic encephalopathy have evolved, with a focus on overt and covert forms, and the recognition of the impact of mild forms on quality of life and the risk of developing overt hepatic encephalopathy 1.
From the Research
Complications of Hepatic Encephalopathy
The most serious complications of hepatic encephalopathy (HE) include:
- Ascites and variceal bleeding, with HE being the most serious complication of decompensated liver cirrhosis 2
- Low-grade cerebral oedema with oxidative/nitrosative stress, inflammation, and disturbances of oscillatory networks in the brain 2
- Neurological and psychiatric abnormalities ranging from subclinical alterations to coma 3
- High mortality rates, with 1-year mortality rates of almost 60% 4
Clinical Relevance and Healthcare Burden
HE is a severe complication of liver disease, and its clinical relevance and healthcare burden are significant, with:
- HE being the leading cause for hospital readmission, intensive care treatment, and mortality in patients with chronic liver disease 3
- A high clinical relevance and healthcare burden that underlines the need for further research into the pathomechanisms of HE and the development of novel therapies 3
Treatment and Management
The treatment and management of HE involve:
- Lactulose and rifaximin as the mainstay of medical treatment, with a focus on resolving ammonia accumulation and identifying and removing precipitating factors 2, 5
- Alternative treatments, such as zinc, antibiotics, ornithine aspartate, sodium benzoate, probiotics, and surgical intervention, which are usually second-line in patients who do not respond to lactulose 4
- Newer therapies, such as manganese chelators, L-carnitine, N-methyl-d-aspartate receptor antagonists, blood purification dialysis system, and an intravenous combination of sodium benzoate and phenylacetate, which are still in development 4