Initial Management of Encephalopathy

Immediate Assessment and Stabilization

The American College of Physicians and the Infectious Diseases Society of America recommend distinguishing true encephalitis from encephalopathy, as this fundamentally changes management, with encephalitis requiring urgent empiric acyclovir and lumbar puncture, while encephalopathy demands identification and correction of precipitating factors 1, 2
Patients with altered consciousness who cannot protect their airway require immediate intubation, particularly if there is risk of aspiration or Glasgow Coma Scale deterioration, as recommended by the Journal of Infection 3, 4
Higher grades of encephalopathy necessitate intensive care monitoring, according to the Clinical Infectious Diseases and Journal of Hepatology guidelines 1, 5

The Infectious Diseases Society of America recommends starting IV acyclovir immediately before diagnostic results return, as HSV encephalitis has high mortality without treatment, with a strength of evidence rated as high 3, 6
The Journal of Infection suggests continuing acyclovir for 14 days if HSV is confirmed, with a moderate strength of evidence 3, 6
A CT brain scan should be performed before lumbar puncture in most patients to exclude contraindications, as recommended by the Journal of Infection, with a high strength of evidence 3, 6

The Journal of Hepatology recommends identifying and correcting precipitating factors, which resolves 90% of cases, with a high strength of evidence 5, 7, 8
Lactulose is the first-line therapy for hepatic encephalopathy, with a dosage of 30-45 mL (20-30 g) orally three to four times daily, titrated to produce 2-3 soft stools per day, as recommended by the Journal of Hepatology and Praxis Medical Insights, with a high strength of evidence 5, 7, 8
Rifaximin 550 mg twice daily reduces recurrence risk by 58% when added to lactulose, according to Praxis Medical Insights, with a moderate strength of evidence 7

The Journal of Infection and Praxis Medical Insights warn against delaying acyclovir while awaiting LP or imaging if encephalitis is suspected, as mortality is high without treatment, with a high strength of evidence 3, 6
The Journal of Hepatology and Praxis Medical Insights advise against relying on ammonia levels alone for diagnosis or monitoring of hepatic encephalopathy, with a moderate strength of evidence 5, 7

The Journal of Hepatology recommends secondary prophylaxis with lactulose after the first episode of hepatic encephalopathy to prevent recurrence, with a high strength of evidence 5, 7, 8
Liver transplantation evaluation should be initiated after the first episode of hepatic encephalopathy or if recurrent/intractable despite therapy, according to the Journal of Hepatology, with a moderate strength of evidence 5, 7