Hepatic encephalopathy (HE)

Hepatic encephalopathy (HE)

Hepatic encephalopathy (HE) is defined as “a condition which reflects a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction after exclusion of other known brain disease.”

Clinical presentation

Stage I

• Mild confusion

• Agitation

• Irritability

• Sleep disturbance

• Decreased attention

Stage II

• Lethargy

• Disorientation

• Inappropriate behavior

• Drowsiness

Stage III

• Somnolent but arousable

• Slurred speech

• Confused

• Aggressive behavior

Stage IV

• Coma

Pharmacological treatment

• L-Ornithine L-Aspartate (IV) 10 g 8 hourly daily for 3–5 days

  
  

  THEN

• L-Ornithine L-Aspartate (PO) 9 g 24 hourly in divided doses for 4–12 weeks

AND

• Lactulose solution (PO) for bowel cleansing when required

Episode of hepatic encephalopathy (grade 2 or higher) — enemas

• 0.9% sodium chloride 300 mL in 1000 mL water 2 hourly until there is clinical improvement

Episode of hepatic encephalopathy (able to tolerate oral administration)

• Lactulose (PO): 45 mL every hour until there is bowel movement and clinical improvement

Outpatient therapy

• Lactulose (PO): 15–45 mL 8–12 hourly until there are 2–3 bowel movements per day

Additional pharmacological treatment

• Metronidazole (PO) 400 mg 8 hourly for 7 days

  
  

  AND

• Ceftriaxone (IV) 1 g 12 hourly for 7 days (if evidence of spontaneous bacterial peritonitis)

Precipitants of hepatic encephalopathy

Metabolic and electrolyte causes

• Hyponatremia

• Hypokalemia

• Alkalosis

• Azotemia

• Dehydration

Gastrointestinal causes

• Gastrointestinal bleeding

• Diarrhea

• Vomiting

• Constipation

• Excessive paracentesis

Infectious causes

• Infection

Drug-related causes

• Sedative drugs (narcotics, sleep aids, antihistaminics)

• Diuretics

Other causes

• Surgery

• Fluid restriction

• Excessive protein intake