Plasma ammonia should be measured in patients with delirium/encephalopathy and liver disease, since an HE diagnosis is questionable in the context of a normal value.
Non-absorbable disaccharides should be used to treat patients with covert HE.
Liver transplantation should be considered for patients with recurrent or persistent HE; referral should be made for evaluation at a transplant center in response to a first episode of overt HE.
Secondary prophylaxis with lactulose is recommended after a first episode of overt HE; the lactulose should be titrated so that 2-3 daily bowel movements are achieved.
It is recommended that rifaximin be used for secondary prophylaxis (as an adjunct to lactulose) should one or more additional episodes of overt HE occur within 6 months of the initial one.
HE can be prevented in patients presenting with gastrointestinal bleeding by rapidly removing blood from the gastrointestinal tract (lactulose or mannitol by nasogastric tube or lactulose enemas).
Prior to non-urgent placement of a transjugular intrahepatic portosystemic shunt (TIPS), rifaximin can be considered for HE prophylaxis in patients with cirrhosis and past episodes of overt HE. Further study of non-absorbable disaccharides, as a standalone or in combination, would be worthwhile in this context.
Routine zinc supplementation in patients with HE is not recommended.
Patients with hepatic myelopathy should be considered as soon as possible for liver transplantation, since no other therapeutic option exists.
Dopaminergic therapy should be tested in patients with Parkinsonism associated with cirrhosis.
For more information, please go to Hepatic Encephalopathy.
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Cite this: Hepatic Encephalopathy Clinical Practice Guidelines (EASL, 2022) - Medscape - Sep 06, 2022.