Management of Hepatic Encephalopathy

The approach to the patient with hepatic encephalopathy depends upon the severity of mental status changes and upon the certainty of the diagnosis. As an example, a patient with known cirrhosis and mild complaints of decreased concentration might be served best by an empiric trial of rifaximin or lactulose and a follow-up office visit to check its effect. However, the patient presenting in hepatic coma requires a different approach. General management recommendations include the following:

- Exclude nonhepatic causes of altered mental function.
- Consider checking an arterial ammonia level in the initial assessment of a hospitalized patient with cirrhosis and with impaired mental function. Ammonia levels have less use in a stable outpatient.
- Precipitants of hepatic encephalopathy, such as metabolic disturbances, gastrointestinal bleeding, infection, and constipation, should be corrected.
- Avoid medications that depress central nervous system function, especially benzodiazepines. Patients with severe agitation and hepatic encephalopathy may receive haloperidol as a sedative. Treating patients who present with coexisting alcohol withdrawal and hepatic encephalopathy is particularly challenging. These patients may require therapy with benzodiazepines in conjunction with lactulose and other medical therapies for hepatic encephalopathy.
- Patients with severe encephalopathy (ie, grade 3 or 4) who are at risk for aspiration should undergo prophylactic Endotracheal intubation. They are optimally managed in the intensive care unit.
- Fanelli et al investigated the efficacy of using an hourglass-shaped expanded polytetrafluoroethylene (ePTFE) stent-graft to treat patients whose hepatic encephalopathy was refractory to conventional medical therapy. In the study, 12 patients who, subsequent to receiving a transjugular intrahepatic portosystemic shunt, had developed refractory hepatic encephalopathy underwent shunt reduction with the stent-graft.
- The reduction procedure immediately produced a portosystemic gradient increase in the above study’s patients, who, within 18-26 hours after insertion of the stent-graft, no longer exhibited symptoms of hepatic encephalopathy. The condition did not recur over a mean follow-up period of 74 weeks. Over the course of the study, 4 patients died of cardiovascular failure, another underwent orthotopic liver transplantation, and 2 more were lost to follow-up. The 5 remaining patients finished the study in good clinical condition. The authors concluded that hourglass-shaped ePTFE stent-grafts appear to effectively reduce shunt flow and quickly improve patients’ clinical conditions.

Most current therapies are designed to treat the hyperammonemia that is a hallmark of most cases of hepatic encephalopathy.