Hepatic Encephalopathy Management

Classification and Diagnosis

Hepatic encephalopathy (HE) should be classified according to the West Haven criteria when temporal disorientation is present (grades ≥2), with the Glasgow Coma Scale added for grades III-IV, while neuropsychological or neurophysiological testing should be used to diagnose covert HE in patients with mild or no neuropsychiatric abnormalities 1, 2
Type A HE is due to acute liver failure, Type B is due to portosystemic shunt without significant liver disease, and Type C is due to cirrhosis with or without portosystemic shunt 2
Covert HE includes minimal HE and Grade I, with minimal HE having no obvious clinical signs but abnormalities on neuropsychological/neurophysiological tests, and Grade I having mild alterations in consciousness, subtle personality/behavior changes, decreased attention, sleep disturbances, irritability, and difficulty with complex cognitive tasks 2, 3

A four-pronged approach is recommended for all grades of HE, including initiation of care for patients with altered consciousness, identification and treatment of alternative causes of altered mental status, identification and correction of precipitating factors, and commencement of empirical HE treatment 4, 5
Testing for covert HE should be considered in patients with impaired quality of life, employment implications, or public safety concerns, and treatment is not routinely recommended but may be considered in specific circumstances affecting daily functioning 4, 6
Lactulose is recommended as first-line treatment for Grade II HE, titrated to achieve 2-3 soft stools per day, and identify and correct precipitating factors such as infections, GI bleeding, constipation, dehydration, and electrolyte disturbances 3, 5
Grade III-IV HE requires intensive care monitoring due to risk of airway compromise, and add Glasgow Coma Scale assessment for monitoring, with lactulose administration and consideration of rifaximin as add-on therapy for patients with recurrent episodes 1, 2, 4, 5, 7

Brain imaging (CT/MRI) should be performed to exclude other causes of altered mental status, particularly for first-time HE, and blood ammonia levels alone do not add diagnostic, staging, or prognostic value 4, 6, 7
An episode of overt HE should be actively treated, and secondary prophylaxis after an episode of overt HE is recommended, with primary prophylaxis not required except in patients with cirrhosis at high risk for developing HE 4, 6
Recurrent intractable overt HE, together with liver failure, is an indication for liver transplantation 4, 6
Common pitfalls to avoid include failing to identify and treat precipitating factors, relying solely on ammonia levels for diagnosis or monitoring, not considering secondary prophylaxis after the first episode of overt HE, inadequate titration of lactulose dosage, and confusing hepatic encephalopathy with other causes of altered mental status 3, 4, 5