Hepatic Encephalopathy and Wernicke's Encephalopathy Management

Diagnosis and Classification

The American Association for the Study of Liver Diseases recommends classifying hepatic encephalopathy into different severity grades using the West-Haven criteria, which include Grade I-II: personality changes, mild confusion, attention deficits, and Grade III-IV: progressive disorientation, acute confusional state, stupor, and coma 1
A CT scan of the brain should be performed to rule out other causes of altered mental status 1

The European Association for the Study of the Liver recommends that patients with higher grades of encephalopathy who cannot protect their airways require intensive monitoring and should be treated in an intensive care unit 3
The head of the patient should be elevated by 30 degrees to reduce intracranial pressure 3
Intubation is recommended for patients with Grade III-IV hepatic encephalopathy to protect the airways 1
Sedatives should be avoided whenever possible, as they can impair neurological assessment 3

Controlling triggering factors is crucial, as nearly 90% of patients can be treated solely by correcting the precipitating factor 2
Common triggering factors include infections 1, gastrointestinal bleeding 4, electrolyte disturbances (particularly hyponatremia <130 mmol/L) 5, medication non-compliance 3, constipation 3, and proton pump inhibitors (PPIs) which should be restricted to strict validated indications 5
Benzodiazepines are contraindicated in decompensated liver cirrhosis 5

Lactulose is recommended as first-line therapy, with a dosage of 25 ml lactulose syrup every 12 hours, until at least two soft or loose stools per day are achieved 2
Rifaximin should be added when the patient's condition does not improve with lactulose alone 3

Secondary prophylaxis is recommended after an episode of hepatic encephalopathy, using lactulose, and adding rifaximin in cases of recurrent encephalopathy 2
Patient education on the effects and potential side effects of medications, the importance of treatment adherence, early signs of recurrent hepatic encephalopathy, and measures to take in case of recurrence is crucial 4, 7
Monitoring of sodium levels in the blood is recommended in patients with decompensated liver cirrhosis, as severe hyponatremia is a predisposing factor for hepatic encephalopathy 5
Avoidance of benzodiazepines and restriction of PPIs to strict indications is recommended 5

Recurrent, treatment-refractory hepatic encephalopathy combined with liver failure is an indication for liver transplantation 2
Liver transplantation leads to significant improvement in most cognitive functions in patients with hepatic encephalopathy 6
A neurological examination should be performed before transplantation to rule out other causes of neurological or neuropsychological impairment 6