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Semin Liver Dis 2007; 27: 032-048
DOI: 10.1055/s-2007-984576
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

An Algorithm for the Management of Hepatic Encephalopathy

Kevin D. Mullen1 , Peter Ferenci2 , Nathan M. Bass3 , Carroll B. Leevy4 , Emmet B. Keeffe5
  • 1Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio
  • 2Department of Internal Medicine III, Gastroenterology and Hepatology, University of Vienna, Vienna, Austria
  • 3Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
  • 4University of Medicine and Dentistry of New Jersey, Newark, New Jersey
  • 5Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, California
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Publication History

Publication Date:
14 August 2007 (online)

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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.

KEYWORDS

Hepatic encephalopathy - treatment guidelines - diagnosis - pharmacotherapy

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Kevin D MullenM.D. 

MetroHealth Medical Center

2500 MetroHealth Drive, Cleveland, OH, 44109

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