Hepatische Enzephalopathie bei Leberzirrhose

Die hepatische Enzephalopathie (HE) ist eine häufige Komplikation der Leberzirrhose mit signifikanter Morbidität und Mortalität. Eine frühzeitige Erkennung und individualisierte Therapie der HE sind entscheidend, um Lebensqualität, Prognose und Alltagsfunktion der Patient*innen mit Leberzirrhose zu verbessern. Dieser Beitrag gibt einen Überblick über praxisnahe Diagnose- und Management-Strategien der HE bei Patient*innen mit Leberzirrhose.

Abstract

Hepatic encephalopathy (HE) is a common and serious complication of liver cirrhosis, associated with significant morbidity and mortality. Pathophysiologically, it results from a complex interplay of hyperammonemia, systemic inflammation, neuroinflammatory processes, and microbial dysbiosis. Clinically, HE ranges from subtle cognitive impairments (minimal HE) to coma (grade 4 HE). Diagnosis requires thorough clinical assessment and the use of specialized testing methods, particularly to detect subclinical alterations. In everyday practice, ammonia levels have limited diagnostic value but may be useful for differential diagnosis. The acute treatment of overt hepatic encephalopathy (OHE) is primarily based on the administration of lactulose, optionally supplemented with intravenous L-ornithine-L-aspartate. For secondary prophylaxis lactulose is the treatment of choice and in patients with recurrent episodes, the combination of rifaximin and lactulose is well established. Nutritional recommendations are a key component of therapy, especially to prevent sarcopenia. In cases of refractory HE or recurrent relapses despite guideline-based treatment, liver transplantation should always be considered. In general, early detection and individualized management of HE is essential to preserve and improve quality of life, prognosis, and functional independence of the affected patients.

Kernaussagen

• Die hepatische Enzephalopathie (HE) ist eine häufige Komplikation der Leberzirrhose und wird im Alltag oft übersehen.

• Die Pathophysiologie ist komplex und fußt auf einem Zusammenspiel aus Hyperammonämie, systemischer Inflammation, neuroinflammatorischen Prozessen und mikrobieller Dysbiose.

• Die HE wird anhand der West-Haven-Klassifikation eingeteilt.

• Die Akuttherapie der overten HE (OHE) basiert auf der Gabe von Laktulose, ggf. ergänzt durch L-Ornithin-L-Aspartat.

• Eine Sekundärprophylaxe sollte mit Laktulose durchgeführt werden. Nach einem Durchbruch-Rezidiv sollte Rifaximin ergänzt werden.

• Eine suffiziente Ernährung (mit ausreichender Protein-Zufuhr) ist die Basis der Primär- und Sekundärprophylaxe.

Schlüsselwörter

Leberzirrhose - hepatische Enzephalopathie - Dekompensation - kognitive Dysfunktion

Keywords

cirrhosis of the liver - hepatic encephalopathy - decompensation - cognitive dysfunction

Publication History

Article published online:
09 February 2026

• Literatur

• 1 Gu W, Hortlik H, Erasmus HP. et al. Trends and the course of liver cirrhosis and its complications in Germany: Nationwide population-based study (2005 to 2018). Lancet Reg Health Eur 2022; 12: 100240
• 2 European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. J Hepatol 2022; 77: 807-824
• 3 Nagel M, Weidner V, Schulz S. et al. Continued alcohol consumption and hepatic encephalopathy determine quality of life and psychosocial burden of caregivers in patients with liver cirrhosis. Health Qual Life Outcomes 2022; 20: 23
• 4 Labenz C, Baron JS, Toenges G. et al. Prospective evaluation of the impact of covert hepatic encephalopathy on quality of life and sleep in cirrhotic patients. Aliment Pharmacol Ther 2018; 48: 313-321
• 5 Gerbes AL, Labenz J, Appenrodt B. et al. Updated S2k-Guideline „Complications of liver cirrhosis“. German Society of Gastroenterology (DGVS). Z Gastroenterol 2019; 57: 611-680
• 6 Rose CF, Amodio P, Bajaj JS. et al. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol 2020; 73: 1526-1547
• 7 Haussinger D, Dhiman RK, Felipo V. et al. Hepatic encephalopathy. Nat Rev Dis Primers 2022; 8: 43
• 8 Gairing SJ, Mangini C, Zarantonello L. et al. Prevalence of minimal hepatic encephalopathy in patients with liver cirrhosis: a multicenter study. Am J Gastroenterol 2023; 118 (12) 2191-2200
• 9 Erminelli D, Mangini C, Zarantonello L. et al. Overt Hepatic Encephalopathy: More Than Meets the Eye. Am J Gastroenterol 2024; 119 (09) 1930-1934
• 10 Vilstrup H, Amodio P, Bajaj J. et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014; 60: 715-735
• 11 Labenz C, Beul L, Toenges G. et al. Validation of the simplified Animal Naming Test as primary screening tool for the diagnosis of covert hepatic encephalopathy. Eur J Intern Med 2019; 60: 96-100
• 12 Labenz C, Gairing SJ, Kaps L. et al. QuickStroop for screening for minimal hepatic encephalopathy in patients with cirrhosis. JHEP Rep 2025; 7: 101298
• 13 Gallego-Duran R, Hadjihambi A, Ampuero J. et al. Ammonia-induced stress response in liver disease progression and hepatic encephalopathy. Nat Rev Gastroenterol Hepatol 2024; 21: 774-791
• 14 Gairing SJ, Muller L, Kloeckner R. et al. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55: 1265-1276
• 15 Bureau C, Thabut D, Jezequel C. et al. The Use of Rifaximin in the Prevention of Overt Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt: A Randomized Controlled Trial. Ann Intern Med 2021; 174: 633-640