Hepatic Encephalopathy (HE)

Kayley Josephs

Categories

  • Type A: in patients with acute liver failure 
  • Type B: in patients with portosystemic shunt without significant liver disease 
  • Type C: in patients with cirrhosis

Severities

  • Covert HE: abnormalities on psychometric and/or neurophysiological tests +/- minimal clinical signs/symptoms 
  • Overt HE: clinically appreciable change in mental status (e.g., AxOx2 or asterixis) 
  • Recurrent: ≥ 2 bouts within 6 months 
  • Persistent: no return to baseline mental status between episodes

Evaluation

  • Asterixis: inability to maintain stable posture (many ways to assess). For example, “Hold out both hands like you are stopping traffic” (if following commands) 
  • Check for clonus 
  • Shine light in pupils to assess for hippus 

Clinical grading (West-Haven )

Grade

Behavior Change

I (covert)Mild confusion, changes in behavior, increased sleep, no asterixis, cannot be confirmed without neuropsych testing
II (overt)Moderate confusion, lethargic, AAOx2, +asterixis
III (overt)Marked confusion (stupor), sleeping but arousable, incoherent speech, AAOx1, asterixis
IV (overt)Coma, unresponsive to painful stimuli

Identify precipitating cause (IBLED: infection, bleeding, lactulose deficiency, Electrolytes, Diuretics/drugs)

  • Infection (rule out SBP + CXR, BCx, UA/UCx), 
  • Medication non-adherence (lactulose) 
  • GI bleed (perform rectal exam and trend Hgb) 
  • Overdiuresis -> hypovolemia, electrolyte abnormalities (especially hypoK) 
  • Sedatives/benzo/opiate used (UDS) 
  • Brain imaging does not provide any diagnostic value for HE but may be utilized if diagnostic uncertainty exists 

*Elevated ammonia (NH3) levels do not add any diagnostic, staging, or prognostic value in chronic liver disease. However, a normal ammonia level calls for diagnostic re-evaluation. Arterial NH3 is used in acute liver failure for prognostication (not for management).

Management

  • Treat underlying precipitant 
  • Lactulose 30-45mL BID to q6h (initially) titrated to 3-5 BMs/day as secondary prophylaxis after the management of first episode of overt HE 
    • Avoid excessive stool output which may exacerbate HE due to dehydration and electrolyte abnormalities
    • Consider lactulose enemas vs DHT placement if unable to tolerate PO (DHT is NOT contraindicated in patients with esophageal varices. Consider waiting 24h prior to placing DHT in patient who just had banding) 
  • Add Rifaximin after the second episode of HE, or failure to respond to lactulose 
    • Frequently requires prior authorization for outpatient approval + expensive 
  • Consider adding golytely as it has been shown in RCTs to expedite resolution of severe HE by 1 day 

*Lactulose is generally continued indefinitely after first episode of HE, though discontinuation can be considered on an individual basis if predisposing factors (recurrent infection, EVH, EtOH use) have resolved, improvement in liver function, and improvement in nutritional status

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