An Algorithm for the Management of Hepatic Encephalopathy

ABSTRACT

Hepatic encephalopathy (HE) is a serious and progressive, but potentially reversible, neuropsychiatric complication associated with both acute liver failure and advanced chronic liver disease. Currently, no gold standard exists for the diagnosis and treatment of HE, particularly its mildest form, minimal HE. Recently, a panel of international hepatologists met to develop practical recommendations for the diagnosis and treatment of HE. Their recommendations were based on current understanding of the pathogenesis of HE, the availability of practical diagnostic methods, and the efficacy, safety, and cost of available therapies. The panel recommendations include screening all patients with cirrhosis for minimal HE using psychometric testing, because of the association of this disorder with variable degrees of impaired functional status and decreased health-related quality of life. Pharmacologic therapy is recommended for patients diagnosed with minimal HE. If psychometric testing is unavailable, a trial of therapy is recommended when patient history suggests the presence of minimal HE. Initial management of overt HE involves detection and treatment of precipitating causes, followed by measures to lower the blood ammonia concentration. The recommendations to restrict driving privileges in patients with overt HE should be individualized. Although well-performed, placebo-controlled studies of lactulose therapy are lacking, clinical experience with the disaccharides supports their use in the management of HE. The safety profile and efficacy of the oral nonabsorbable antibiotic rifaximin make it a viable alternative therapy for HE. Ongoing studies will better define the role rifaximin and other potentially useful pharmacotherapies under study including acarbose, l-ornithine-l-aspartate, levocarnitine, and probiotics.

Hepatic encephalopathy - treatment guidelines - diagnosis - pharmacotherapy

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