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HWN Suggests

Hepatic Encephalopathy: A Rapid Review

So… what’s the treatment? Lactulose is the first line to encourage bowel movements (although newer evidence suggests PEG3350 may be superior). It is given orally at a dose of 10-30g (15-45mL) every 1-2 hours until there is a bowel movement. In patients who cannot tolerate PO medication, enemas are possible. After a bowel movement is achieved, continue with lactulose 2-4 times per day targeting 3-4 bowel movements per day.

Rifaximin is a non-absorbable antibiotic. It is used as a second line or in combination with lactulose. Emerging evidence suggests rifaximin monotherapy is superior to lactulose monotherapy. Currently this medication is used as maintenance therapy in patients with recurrent…

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 EM@3AM: Hepatic Encephalopathy

This is primarily a diagnosis of exclusion that occurs in patients with severe liver disease, primarily due to nitrogen waste accumulation and increased metabolism of ammonia to glutamine in the CNS. It occurs with increased nitrogen load, decreased toxin clearance, and alteration in neurotransmitters.

 Hepatic Encephalopathy: Common Precipitants, Sneaky Precipitants, and Clinical Pearls

Hepatic encephalopathy may not resolve until the inciting event is treated1. Avoid benzodiazepines and opiates, as these can potentiate hepatic encephalopathy. In the setting of current alcoholism, consider Wernicke-Korsakoff syndrome as a mimic of HE and treat empirically with thiamine. Lactulose and rifaximin are standard treatment in the ED and can be started in the clinically stable patient prior to admission

Articles of Interest

Hepatic Encephalopathy

The majority of patients with cirrhosis will eventually develop complications related to portal hypertension. One of these recurrent and difficult to treat complications is hepatic encephalopathy (HE). Studies have indicated that overt hepatic encephalopathy affects 30 to 45% of patients with cirrhosis and a higher percentage may be affected by minimal degree of encephalopathy.

Hepatic encephalopathy in chronic liver disease

The closest we have to a definitive “test” for hepatic encephalopathy is improvement following therapy – but even this isn't 100% specific. Many forms of metabolic encephalopathy will improve with supportive care.

Hepatic Encephalopathy In The ED

This is an excellent review and guide of do’s and don’ts to patients who present to the ED with mental status changes and highly suspicious to have hepatic encephalopathy (HE) .

Hepatic Encephalopathy – Diagnosis & Management

Lactulose 25-30ml q1-2h until frequent BM, then down-titrate to target 2-3 daily bowel movements. If Lactulose has proven ineffective within 48h, consulting services may add Rifaximin 550mg PO bid or PEG.

Hepatic encephalopathy: An updated approach from pathogenesis to treatment

One of the most serious complications of chronic or fulminant liver failure is hepatic encephalopathy (HE), associated most commonly with cirrhosis. In the presence of chronic liver disease, HE is a sign of decompensation, while in fulminant liver failure its development represents a worrying sign and usually indicates that transplantation will be required.

Liver Emergencies: Acute Liver Failure, Hepatic Encephalopathy...

Rifaximin 400-550 mg po daily – this antibiotic is not absorbed through the gut, eradicates E. Coli which produces ammonia, and is used for long term maintenance of patients with recurrent hepatic encephalopathy. Elevated ammonia levels do not add diagnostic or prognostic value in liver patients suspected of hepatic encephalopathy. Encephalopathy can precede the rise in ammonia levels.

Probiotics for people with hepatic encephalopathy

Whether probiotics are better than lactulose for hepatic encephalopathy is uncertain because the quality of the available evidence is very low. High-quality randomised clinical trials with standardised outcome collection and data reporting are needed to further clarify the true efficacy of probiotics.

Severe hepatic encephalopathy: an osmotic shift in management

Thus, treating plasma osmolarity is key. This is usually done, in extreme cases treated in ICUs, by using mannitol or hypertonic saline. Measures to reduce serum ammonia are still worth attempting. The combination of such strategies can buy time to allow hepatic function to recover...

The Management of Hepatic Encephalopathy from Ward to Domiciliary Care: Current Evidence and Gray Areas

Once the diagnostic process is complete, a correct treatment should be started. The anti-HE treatment is based on a combination of the correction of precipitants; non-absorbable antibiotics, such as rifaximin; and non-absorbable disaccharides.