Hepatic Encephalopathy Management

Introduction to Hepatic Encephalopathy

The European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines recommend a structured approach for all patients with overt hepatic encephalopathy, which includes stabilizing patients with altered consciousness, excluding alternative causes of altered mental status, identifying and correcting precipitating factors, and beginning empirical lactulose therapy 1, 2

Common precipitating factors that must be systematically evaluated and corrected include infections, gastrointestinal bleeding, constipation, dehydration and electrolyte disturbances, sedative medications, and proton pump inhibitors, according to the EASL/AASLD guidelines 4

Lactulose is FDA-approved and recommended as initial treatment for all episodes of overt hepatic encephalopathy, with a dosing goal of 25 mL orally every 12 hours, titrated to achieve 2-3 soft bowel movements per day, as recommended by the EASL/AASLD guidelines 1, 2
The American Association for the Study of Liver Diseases recommends lactulose as the first-line treatment for hepatic encephalopathy, with a strength of evidence of Grade 1, as it is effective in reducing the risk of overt HE recurrence 1, 2

After the first episode of overt hepatic encephalopathy, continue lactulose indefinitely as secondary prophylaxis, which is a GRADE I, A, 1 recommendation, according to the EASL/AASLD guidelines 1, 2, 4, 3

A normal ammonia level should prompt diagnostic reevaluation for alternative causes of altered mental status, as elevated ammonia alone does not add diagnostic, staging, or prognostic value, according to the EASL/AASLD guidelines 2, 3, 4

The first episode of overt hepatic encephalopathy should prompt referral to a transplant center for evaluation, and recurrent intractable overt HE, together with liver failure, is a GRADE I indication for liver transplantation, according to the EASL/AASLD guidelines 1, 2, 3