Hepatic Encephalopathy - Diagnosis and Management Summary

Definition:

 • Alteration in brain function manifested by neuropsychiatric symptoms

 • Caused by liver insufficiency and/or portosystemic shunting

 • * Diagnosis of exclusion: always rule out other causes of neurologic/cognitive impairment

Prevalence: At cirrhosis diagnosis: 10-14%. If decompensated: 16-21%

Incidence: Occurs in 30-40% over course of disease

Recurrence: Up to 40% over a 30-day period

Precipitants: Infection, GI bleeding, Diuretic overdose, Electrolyte imbalances, Constipation, Alcohol binge, Malnutrition, TIPS

West Haven Criteria:

 • Grade 1: Trivial lack of awareness, Altered sleep, Shortened attention span, Impaired addition

 • Grade 2: Lethargy, apathy, Personality change, Asterixis, Inappropriate behavior, Disorientation to time, place

 • Grade 3: Somnolence (but responsive), Confusion, Gross disorientation

 • Grade 4: Coma (unresponsive to verbal or noxious stimuli)

TREATMENT

Initiate empiric treatment while identifying and addressing any precipitating factors

Lactulose: non-absorbable disaccharide that is metabolized to lactic acid by colonic bacteria, acidifying the lumen and promoting NH3 -> NH4+ (which is trapped in lumen and excreted)

 • Titrate to maintain 2-3 bowel movements per day

 • Beware of dehydration, electrolyte abnormalities

 • Polyethylene glycol can be used in cases of lactulose intolerance

Rifaximin: non-absorbable antibiotic, thought to reduce ammonia-producing colonic bacteria

 • Guidelines recommend using as add-on to lactulose to prevent recurrence

Other therapies to consider: Zinc supplementation, IV L-ornithine L-aspartate (LOLA), oral branched chain amino acids *Supporting data is limited

Diet: protein restriction is detrimental!

 • Skeletal muscle metabolizes ammonia important to avoid malnutrition and promote building muscle mass



- Lizzie Aby, MD @LizzieAbyMD



#Hepatic #Encephalopathy #Grading #Classification #Diagnosis #Management #treatment #hepatology