Managing the Risk of Hepatic Encephalopathy

Screening and Diagnosis

All patients with cirrhosis should be systematically screened for both overt and covert hepatic encephalopathy (HE), regardless of liver function status, as recommended by the European Association for the Study of the Liver 1, 2
The animal naming test is recommended as a simple, rapid bedside screening tool that can be performed by physicians, nurses, and caregivers in just 60 seconds, according to the European Association for the Study of the Liver 3, 1
Diagnostic workup should include blood tests for glucose, electrolytes, inflammatory markers, full blood count, blood alcohol level, ammonia, thyroid-stimulating hormone, and brain imaging when appropriate, as suggested by the European Association for the Study of the Liver 4

Common precipitating factors that must be addressed include infections, gastrointestinal bleeding, electrolyte disturbances, particularly hyponatremia, medication non-compliance, constipation, and proton pump inhibitors, which should be restricted to strict validated indications, as recommended by the American Association for the Study of Liver Diseases 1, 5, 6
Benzodiazepines are contraindicated in decompensated liver cirrhosis, according to the American Association for the Study of Liver Diseases 5

Lactulose is recommended as first-line therapy for both acute overt HE and prevention of recurrence, with a dosage of 25 ml lactulose syrup every 12 hours, titrated to achieve 2-3 soft stools per day, as suggested by the American Association for the Study of Liver Diseases 5
Rifaximin (550 mg twice daily) should be added when the patient's condition does not improve with lactulose alone or for prevention of recurrent episodes after a second episode of HE, according to the American Association for the Study of Liver Diseases 5, 7

Secondary prophylaxis is recommended after an episode of HE using lactulose, with rifaximin added for recurrent encephalopathy, as suggested by the European Association for the Study of the Liver 5, 7
Managing complications of cirrhosis, such as spontaneous bacterial peritonitis and GI bleeding, according to available guidelines is essential, as recommended by the European Association for the Study of the Liver 7, 8
Nutritional support is critical, as weight loss with sarcopenia may worsen HE, and providing enough protein and energy to favor positive nitrogen balance and increase muscle mass is recommended, according to the European Association for the Study of the Liver 7, 8

Patients with higher grades of encephalopathy who cannot protect their airways require intensive monitoring and should be treated in an intensive care unit, as suggested by the American Association for the Study of Liver Diseases 5
Occlusion of a dominant portosystemic shunt may improve HE in patients with recurring HE and good liver function, though experience is limited, according to the European Association for the Study of the Liver 7

Patient and caregiver education should include effects of medication, potential side effects, importance of treatment adherence, early signs of recurring HE, and actions to take if recurrence occurs, as recommended by the European Association for the Study of the Liver 7
Monitoring neurological manifestations is necessary to adjust treatment, investigate the presence and degree of covert HE or signs of recurring HE, and evaluate gait and walking to consider the risk of falls, according to the European Association for the Study of the Liver 7

Treatment endpoints should cover two key aspects: cognitive performance and daily life autonomy, as suggested by the European Association for the Study of the Liver 7