Last updated March 15, 2022

Hepatic Encephalopathy in Chronic Liver Disease

Recommendations

1. Hepatic encephalopathy (HE) should be classified according to the type of underlying disease, severity of manifestations, time course, and precipitating factors.

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2. A diagnostic workup is required, considering other disorders that can alter brain function and mimic HE.

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3. Hepatic encephalopathy should be treated as a continuum ranging from unimpaired cognitive function with intact consciousness through coma.

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4. The diagnosis of HE is through exclusion of other causes of brain dysfunction.

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5. Hepatic encephalopathy should be divided into various stages of severity, reflecting the degree of self-sufficiency and the need for care.

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6. Overt hepatic encephalopathy is diagnosed by clinical criteria and can be graded according the West Haven Criteria and the Glasgow Coma Scale.

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7. The diagnosis and grading of minimal HE and covert HE can be made using several neurophysiological and psychometric tests that should be performed by experienced examiners.

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8. Testing for minimal HE and covert HE could be used in patients who would most benefit from testing, such as those with impaired quality of life or implication on employment or public safety.

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9. Increased blood ammonia alone does not add any diagnostic, staging, or prognostic Mvalue for HE in patients with chronic liver disease. A normal value calls for diagnostic reevaluation.

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General recommendations for treatment of episodic overt HE type C include the following:

10. An episode of overt HE (whether spontaneous or precipitated) should be actively treated.

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11. Secondary prophylaxis after an episode for overt HE is recommended.

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12. Primary prophylaxis for prevention of episodes of overt HE is not required, except in patients with cirrhosis with a known high risk to develop HE.

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13. Recurrent intractable overt HE, together with liver failure, is an indication for liver transplantation.

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Specific approach to overt HE treatment: A four-pronged approach to management of MHE is recommended.

14. Initiation of care for patients with altered consciousness.

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15. Alternative causes of altered mental status should be sought and treated.

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16. Identification of precipitating factors and their correction.

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17. Commencement of empirical HE treatment.

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18. Identify and treat precipitating factors for HE.

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19. Lactulose is the first choice for treatment of episodic overt HE.

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20. Rifaximin is an effective add-on therapy to lactulose for prevention of overt HE recurrence.

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21. Oral branched-chain amino acids can be used as an alternative or additional agent to treat patients nonresponsive to conventional therapy.

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22. Intravenous L-ornithine L-aspartate can be used as an alternative or additional agent to treat patients nonresponsive to conventional therapy.

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23. Neomycin is an alternative choice for treatment of overt HE.

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24. Metronidazole is an alternative choice for treatment of overt HE.

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25. Lactulose is recommended for prevention of recurrent episodes of HE after the initial episode.

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26. Rifaximin as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after the second episode.

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27. Routine prophylactic therapy (lactulose or rifaximin) is not recommended for the prevention of post-transjugular intrahepatic portosystemic shunt (TIPS) HE.

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28. Under circumstances where the precipitating factors have been well controlled (i.e., infections and variceal bleeding) or liver function or nutritional status improved, prophylactic therapy may be discontinued.

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29. Treatment of minimal HE and covert HE is not routinely recommended apart from a case-by-case basis.

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30. Daily energy intakes should be 35-40 kcal/kg ideal body weight.

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31. Daily protein intake should be 1.2-1.5 g/kg/ day.

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32. Small meals or liquid nutritional supplements evenly distributed throughout the day and a latenight snack should be offered.

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33. Oral branched-chain amino acid supplementation may allow recommended nitrogen intake to be achieved and maintained in patients intolerant of dietary protein.

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Recommendation Grading

Overview

Title

Hepatic Encephalopathy in Chronic Liver Disease

Authoring Organization

Publication Month/Year

July 1, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care in hepatic encephalopathy in chronic liver disease

Target Patient Population

Patients with hepatic encephalopathy in chronic liver disease

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D008107 - Liver Diseases, D008099 - Liver, D008103 - Liver Cirrhosis, D006501 - Hepatic Encephalopathy

Keywords

liver disease, encephalopathy, hepatic encephalopathy, chronic liver disease

Source Citation

DOI: 10.1002/hep.27210