Hepatic Encephalopathy

In a patient with cirrhosis or known portosystemic shunting and altered cognition, first determine whether reduced consciousness compromises airway protection or requires a monitored setting. Grade overt HE clinically with West Haven criteria (WHC) and, when consciousness is impaired, the Glasgow Coma Scale; WHC grade 3 is somnolence with gross disorientation, whereas grade 4 is coma.accessdata fda+2accessdata fda[PDF] 22-554 CROSS DISCIPLINE TEAM LEADER REVIEWaasld[PDF] Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice ...aasldHepatic Encephalopathy in Chronic Liver Disease 2014. ...

Do not label all encephalopathy in cirrhosis as HE. The AASLD/EASL framework requires exclusion of other causes of brain dysfunction; pursue an alternate neurologic, toxic-metabolic, infectious, or structural diagnosis when the presentation is focal, abrupt without a hepatic context, disproportionate to known liver disease, or fails to improve after precipitant correction and HE-directed treatment.aasld+2aasld[PDF] Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice ...aasldHepatic Encephalopathy in Chronic Liver Disease 2014. ...ScienceDirectMinimal/Covert Hepatic Encephalopathy – Impact of Comorbid Conditions - ScienceDirect

Classify the clinical setting because it changes the next action: HE can result from liver insufficiency, portosystemic shunting, or both. Overt HE in cirrhosis defines decompensation; recurrent episodes despite optimized medical therapy should prompt review for a large spontaneous portosystemic shunt, TIPS-associated shunting, and suitability for liver transplantation.Wolters Kluwer+1Wolters KluwerHepatic encephalopathy in chronic liver disease: 2014... : HepatologyScienceDirectHepatic Encephalopathy: Diagnosis and Treatment in Advanced Liver Disease - ScienceDirect

Establish whether the patient has advanced liver disease, portal hypertension, or a portosystemic shunt. HE is defined as brain dysfunction caused by liver insufficiency and/or portosystemic shunting, and overt HE can occur even without cirrhosis when extensive portosystemic shunting is present.ScienceDirect+1ScienceDirectHepatic Encephalopathy: Diagnosis and Treatment in Advanced Liver Disease - ScienceDirectWolters KluwerHepatic encephalopathy in chronic liver disease: 2014... : Hepatology

Perform a directed precipitant evaluation at each overt episode. Infection, renal dysfunction, hyponatremia, diabetes-related metabolic disturbance, and older age can contribute to cognitive dysfunction or increase susceptibility to HE; their presence should trigger correction of the abnormality and reassessment rather than escalation of ammonia-lowering therapy alone.ScienceDirectScienceDirectMinimal/Covert Hepatic Encephalopathy – Impact of Comorbid Conditions - ScienceDirect

Use neuroimaging selectively to evaluate suspected structural disease rather than to establish HE. CT has poor sensitivity for cerebral edema, and structural brain MRI has no validated role as a cognitive test for HE; imaging is therefore most useful when examination or course suggests an alternate intracranial process.BMJBMJHepatic encephalopathy: Part 1, a diagnostic approach

If recurrent HE persists after treatment of precipitating illness and adherence review, evaluate for a major spontaneous portosystemic shunt or problematic TIPS physiology. Shunt embolization has been used for refractory HE associated with large spontaneous portosystemic shunts, while recurrent HE also strengthens the rationale for transplant-directed evaluation in advanced liver disease.Nature+1NatureOptimizing the liver transplant candidate | npj Gut and Liver - NatureWolters KluwerHepatic encephalopathy in chronic liver disease: 2014... : Hepatology

Use lactulose as first-line treatment for symptomatic overt HE and titrate administration to bowel response; a practical target described in clinical use is 2–3 loose stools daily. Reassess hydration status, adherence, stool output, cognition, and the continuing precipitant rather than assuming nonresponse reflects inadequate dose alone.Wolters Kluwer+1Wolters KluwerManagement of Overt Hepatic Encephalopathy - LippincottWileyRetrospective cross‐sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy - Lyon - 2017 - Journal of Gastroenterology and Hepatology - Wiley Online Library

For hospitalized or severe presentations, deliver therapy by the route compatible with mental status and aspiration risk, while airway protection and monitored care take priority in WHC grade 3–4 disease. The treatment endpoint is improvement in cognition and function after correction of reversible drivers, not normalization of a single laboratory marker.accessdata fda+2accessdata fda[PDF] 22-554 CROSS DISCIPLINE TEAM LEADER REVIEWWolters KluwerManagement of Overt Hepatic Encephalopathy - Lippincottaasld[PDF] Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice ...

Polyethylene glycol 3350-electrolyte solution has been studied against lactulose for overt HE, including in the HELP randomized trial, but lactulose and rifaximin remain the preferred therapies in current management discussions. Consider this evidence as an alternative cathartic strategy only within an individualized inpatient plan rather than replacing standard recurrence prevention.Nature+1NatureOptimizing the liver transplant candidate | npj Gut and Liver - NatureOxford AcademicAdvances in the management of complications from cirrhosis

L-ornithine L-aspartate has trial data in HE, but comparative evidence is limited by substantial inclusion of minimal HE and inadequate evidence in severe overt HE. Do not substitute it for lactulose-based first-line management when treating a clinically significant overt episode.Nature+1NatureIntravenous versus oral ‘l-ornithine-l-aspartate’ in overt hepatic encephalopathy: a randomized comparative study | Scientific ReportsWolters KluwerManagement of Overt Hepatic Encephalopathy - Lippincott

After an overt HE episode, maintain lactulose with titration guided by stool response and educate caregivers to recognize underuse, overtreatment, dehydration, and recurrent cognitive change. Inappropriate lactulose use and lack of education have been associated with preventable readmissions; a 2–3 loose stool daily target is commonly used for outpatient titration.Wiley+1WileyRetrospective cross‐sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy - Lyon - 2017 - Journal of Gastroenterology and Hepatology - Wiley Online LibraryWolters KluwerManagement of Overt Hepatic Encephalopathy - Lippincott

For recurrent HE prevention, use rifaximin 550 mg orally twice daily in conjunction with lactulose. Rifaximin is widely used to maintain remission and reduces recurrence, but it is not established as routine monotherapy for prevention; emerging evidence also raises antimicrobial-resistance concerns that should be weighed during prolonged treatment.Wiley+1WileyRetrospective cross‐sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy - Lyon - 2017 - Journal of Gastroenterology and Hepatology - Wiley Online LibraryNatureIncreased risk of antimicrobial resistance in patients with cirrhosis and hepatic encephalopathy using rifaximin | Nature Communications

Covert HE requires formal testing rather than bedside impression alone. PHES is a well-validated psychometric tool; guideline-oriented TIPS screening recommends at least two of PHES, Stroop testing, critical flicker frequency, and spectral-enhanced or quantitative EEG. Treatment may be considered when covert impairment compromises quality of life or creates safety and functional concern.BMJ+2BMJTransjugular intrahepatic portosystemic stent-shunt in the ... - GutWolters KluwerDiagnosis and management of hepatic encephalopathy : Liver ...ScienceDirectHepatic Encephalopathy: Diagnosis and Treatment in Advanced Liver Disease - ScienceDirect

Do not assume that all cognitive impairment in a patient with cirrhosis is covert HE. Diabetes, renal dysfunction, infection, hyponatremia, neurologic disease, thiamine-related dysfunction, and aging complicate interpretation and may require correction or separate evaluation before assigning persistent impairment to HE.ScienceDirectScienceDirectMinimal/Covert Hepatic Encephalopathy – Impact of Comorbid Conditions - ScienceDirect

Screen all patients being considered for elective TIPS for both overt and covert HE because TIPS can precipitate or worsen encephalopathy. Evidence of covert HE is a relative contraindication, and age older than 65 years should increase caution even though it is not an absolute contraindication.BMJ+1BMJTransjugular intrahepatic portosystemic stent-shunt in the ... - GutBMJshunt in the management of portal hypertension - Gut

When a patient has refractory ascites and a normal PHES, reported data suggest a 90% probability of remaining free of HE after TIPS; this is a risk-stratification observation, not a substitute for global assessment of procedural benefit and liver reserve.BMJBMJTransjugular intrahepatic portosystemic stent-shunt in the ... - Gut

For recurrent or refractory HE with a large spontaneous portosystemic shunt, discuss shunt embolization in a multidisciplinary liver setting. This approach has reported safety and efficacy in a multicenter survey, but selection must account for the competing portal-hypertension consequences of reducing shunt flow.NatureNatureOptimizing the liver transplant candidate | npj Gut and Liver - Nature

An overt HE event is a poor prognostic marker. Overt HE occurs in approximately 20% of patients with cirrhosis each year, and one review reported 23% survival at 3 years after onset; HE severity is also associated with short-term mortality independently of extrahepatic organ failure and with 90-day waitlist mortality independently of MELD.BMJ+1BMJHepatic encephalopathy due to liver cirrhosisScienceDirectHepatic encephalopathy 2018: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF) - ScienceDirect