Guideline Video

Guideline Resources

  • Hepatic Encephalopathy
  • American College of Gastroenterology
  • March 3rd, 2026
  • Summary
  • Full-text

Video Transcription

Just published March 3rd, 2026, the American College of Gastroenterology’s newest guideline on Hepatic Encephalopathy.

The guideline focuses on clinical aspects of hepatic encephalopathy, or HE, and provides a framework for ensuring optimal management and improving clinical and psychosocial outcomes during the complex patient journey. There are 24 total recommendations, let’s get started. 

For the section on covert HE (CHE) and minimal HE (MHE), 

  • In patients being evaluated for MHE or CHE, the guideline suggests a single-test strategy over a 2-test combination strategy.
  • In patients being evaluated for MHE or CHE, the guideline suggests against using serum ammonia levels alone to make the diagnosis. 
  • In patients with MHE/CHE, the guideline suggests treatment with lactulose vs no treatment.
  • There is insufficient evidence to recommend for or against routine treatment of MHE/CHE for prevention of overt HE. 

On to the section on inpatient management of HE,

  • In patients with HE, the guideline suggests against routine testing of serum ammonia to guide HE treatment decisions. 
  • In patients with cirrhosis and confusion without new-onset focal neurologic deficits, the guideline suggests against routine brain imaging. 
  • In patients with overt HE, or OHE, the guideline recommends treatment with lactulose to improve patient outcomes and prevent recurrence of OHE episodes. 
  • In patients with OHE, the guideline suggests treatment with high-volume polyethylene glycol preparations as an alternative option to lactulose therapy.
  • In patients with acute OHE, the guideline suggests adding rifaximin to lactulose therapy vs lactulose therapy alone. 

For the section on prevention of HE recurrence, 

  • After an initial episode of OHE, the guideline recommends lactulose titrated to 2–3 soft bowel movements daily as outpatient first-line therapy for prevention of HE recurrence. 
  • In patients treated with lactulose for HE, the guideline suggests using the Bristol Stool Scale with bowel movement frequency for the outpatient titration of lactulose to reduce readmissions.
  • In patients with cirrhosis and OHE, the guideline suggests rifaximin therapy in the outpatient setting to prevent HE recurrence.
  • In patients with OHE on lactulose maintenance therapy who experience recurrent episodes of HE, the guideline recommends addition of rifaximin treatment.
  • In patients with OHE and persistent symptoms despite lactulose and rifaximin therapy, the guideline suggests the addition of zinc supplementation in those with low blood zinc levels. 
  • The guideline suggests implementing health information technology interventions, when feasible, to optimize HE management. 
  • The guideline suggests shunt embolization in patients with refractory HE on optimized medical therapy who have adequate hepatic function and no contraindications.


On to the section on sarcopenia and nutrition, 

  • The guideline recommends a protein intake target of 1.2–1.5 g/kg/d in outpatients with HE.
  • The guideline recommends BCAA supplementation in individuals with HE if protein needs cannot be met by food alone. 
  • The guideline suggests a late-night snack for patients with cirrhosis to reduce frailty and HE. 
  • The guideline suggests against protein restriction in patients with HE because it increases muscle breakdown and does not reduce the duration of HE. 
  • The guideline suggests exercise interventions in patients with HE to reduce the risk for falls, lower portal pressure, and increase the capacity of skeletal muscle for ammonia metabolism. 

For the section on HE in the context of transjugular portosystemic shunt, or TIPS, 

  • The guideline recommends initiating rifaximin therapy 14 days before elective TIPS insertion and continuing for at least 6 months in patients with decompensated cirrhosis with or without a prior episode of OHE to decrease the risk of recurrent or de novo OHE. 
  • The guideline suggests embolizing extrahepatic collaterals at the time of TIPS to reduce post-TIPS HE.

And last for the section on, liver transplant and HE,

  • For patients with multiple HE episodes and MELD score <15, the guideline suggests evaluating candidacy for living donor liver transplantation.

And there you have it. Make sure to check out the full guideline from the American College of Gastroenterology and other related clinical decision support tools at guidelinecentral.com.

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