Hepatic Encephalopathy - Diagnosis and Management Summary Definition: • Alteration in brain function manifested by neuropsychiatric symptoms • Caused by liver insufficiency and/or portosystemic shunting • * Diagnosis of exclusion: always rule out other causes of neurologic/cognitive impairment Prevalence: At cirrhosis diagnosis: 10-14%. If decompensated: 16-21% Incidence: Occurs in 30-40% over course of disease Recurrence: Up to 40% over a 30-day period Precipitants: Infection, GI bleeding, Diuretic overdose, Electrolyte imbalances, Constipation, Alcohol binge, Malnutrition, TIPS West Haven Criteria: • Grade 1: Trivial lack of awareness, Altered sleep, Shortened attention span, Impaired addition • Grade 2: Lethargy, apathy, Personality change, Asterixis, Inappropriate behavior, Disorientation to time, place • Grade 3: Somnolence (but responsive), Confusion, Gross disorientation • Grade 4: Coma (unresponsive to verbal or noxious stimuli) TREATMENT Initiate empiric treatment while identifying and addressing any precipitating factors Lactulose: non-absorbable disaccharide that is metabolized to lactic acid by colonic bacteria, acidifying the lumen and promoting NH3 -> NH4+ (which is trapped in lumen and excreted) • Titrate to maintain 2-3 bowel movements per day • Beware of dehydration, electrolyte abnormalities • Polyethylene glycol can be used in cases of lactulose intolerance Rifaximin: non-absorbable antibiotic, thought to reduce ammonia-producing colonic bacteria • Guidelines recommend using as add-on to lactulose to prevent recurrence Other therapies to consider: Zinc supplementation, IV L-ornithine L-aspartate (LOLA), oral branched chain amino acids *Supporting data is limited Diet: protein restriction is detrimental! • Skeletal muscle metabolizes ammonia important to avoid malnutrition and promote building muscle mass - Lizzie Aby, MD @LizzieAbyMD #Hepatic #Encephalopathy #Grading #Classification #Diagnosis #Management #treatment #hepatology
