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