Hepatische Enzephalopathie Teil 2: Therapie

Die Therapie der hepatischen Enzephalopathie (HE) wird bestimmt von HE-Typ, Schweregrad der kognitiven und neuropsychiatrischen Störungen und möglichen HE-Auslösern – Letztere stehen in der akuten Situation im Vordergrund. Wichtig für Akutbehandlung und Sekundärprophylaxe ist auch die richtige Ernährung bei Leberzirrhose. Die Therapieempfehlungen dieses Beitrags leiten sich in erster Linie von der deutschen und europäischen Leitlinie zur HE ab.

Kernaussagen

• HE-Typ (A, B, C), Schweregrad (klinisch, subklinisch) und Vorliegen eines HE-Auslösers bestimmen das therapeutische Vorgehen. Bei HE-Schweregrad 3 und 4 ist eine intensivmedizinische Betreuung indiziert.

• Die Therapie einer akuten HE-Episode erfolgt ebenso wie die Sekundärprophylaxe nach einer durchgemachten HE primär mit Lactulose.

• Bei Unverträglichkeit oder Unwirksamkeit von nicht resorbierbaren Disacchariden kann auf Rifaximin allein bzw. in Kombination mit Lactulose umgestellt werden.

• Die Evidenz für die Wirksamkeit von L-Ornithin-L-Aspartat bei oHE ist gering und unsicher.

• Die Sekundärprophylaxe nach einer HE-Episode kann beendet werden, wenn ein Auslöser der HE vorlag und erfolgreich therapiert wurde oder sich Ernährungszustand und Leberfunktion gebessert haben.

• Die Primärprophylaxe der HE ist immer nach gastrointestinaler Blutung indiziert. Nach TIPS-Implantation ist sie nur bei früher durchgemachter oHE-Episode angezeigt.

• Eine Proteinrestriktion ist bei Leberzirrhose und HE nicht indiziert.

• Ausreichende Kalorien- und Proteinzufuhr und die Verhinderung längerer Nüchternphasen wirken einer Sarkopenie und dem damit einhergehenden HE-Risiko entgegen.

Schlüsselwörter

hepatische Enzephalopathie - Therapie und Prophylaxe - Lactulose - Rifaximin - L-Ornithin-L-Aspartat

Publication History

Article published online:
12 December 2023

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