Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a complication of cirrhosis which signals decompensation. The presentation can be broad. HE is graded on a scale from I- IV which ranges from irritability and incoordination (I) to fatigue and asterixis (II) and somnolence with clonus (III) all the way to stupor and coma (IV). History and exam can often lead to the diagnosis. Checking an Ammonia level can be useful if there is ambiguity. There is no role in trending levels. There is a precipitating factor in 80% of HE cases which include:

  • infection (SBP)
  • GI bleed
  • medications (opiates, benzos)
  • EtOH
  • electrolyte derrangements (hypokalemia, hyponatremia)
  • hypoglycemia
  • hypoxia
  • clot (portal vein or hepatic vein thrombus)
  • HCC
  • s/p TIPS
  • dehydration

Following diagnosis and assesment for trigger, treatment is classicially with Lactulose. The can be administered PO, via a DHT or enema. Lactulose is dosed with the goal of 3 bowel movements per day. If there is no effect in 48 hours or the symptoms severe (HE III, IV), many suggested adding Rifaximin. A potential alternative to Lactulose is poleyethylene glycol. The HELP clinical trial (published in JAMA 2014) noted more rapid improvement in HE with use of 4L bowel prep with PEG compared to standard Lactulose therapy in a small trial of hospitalized patients with acute HE.