Hepatic Encephalopathy



Approach

Assess for causes:

  • GI Bleeding
  • Sepsis, Dehydration, Electrolyte imbalances
  • Constipation, AKI
  • SBP, Volume Depletion (incl. large vol. paracentesis)
  • Portal/Hepatic Vein Thrombosis
  • Benzodiazepines, Narcotics, Alcohol
  • Hypoglycaemia (cirrhosis patients have ↓↓glycogen)

Investigations

Imaging

  • CT/MRI brain (exclude other causes of ↓GCS
  • Ultrasound abdomen with Doppler Portal Vein
    • Cause of decompensation (e.g. portal thrombus, HCC)

Others

Grade I (West Haven) HE can be assessed using Number Connection Test.

In patients with delirium/encephalopathy and liver disease, where it is unclear if HE is the cause (vs alternative), plasma ammonia can be measured. A normal value suggests a non-HE aetiology of delirium/encephalopathy.

EEG is not used routinely.


Management

  • Lactulose PO or via NG (15-30mls TDS) aiming for 2-3 soft bowel motions/day
  • Enemas 1-2/day if necessary
  • Rifaximin: Used in acute setting after above, and as prophylaxis after confirmed episode of HE at 550mg BD


Content by Dr Íomhar O' Sullivan . Last review Dr ÍOS 21/03/25