Hepatic Encephalopathy Management (AASLD/EASL 2022)

Algorithm Steps

1. ▶

   Start

   Suspected Hepatic Encephalopathy

   Patient with chronic liver disease + altered mental status/neurological changes

   1. ●

      Action

      Confirm HE Diagnosis

      Rule out other causes of altered mental status

      • Known chronic liver disease/cirrhosis
      • Assess for precipitants
      • Rule out: hypoglycemia, electrolyte disorders, infection, intracranial pathology, drugs/toxins
      • CT head if focal neuro signs or no improvement
      1. ◆

         Decision

         Grade HE Severity (West Haven)

         Determine grade to guide management intensity

         • Covert HE: Grade 0-1 (psychometric testing abnormal)
         • Overt HE: Grade 2-4 (clinically apparent)
         1. ●

            Action

            Grade 1: Trivial Lack of Awareness

            Shortened attention, sleep disturbance

            • May have asterixis on exam
            • Start lactulose
            • Identify precipitants
            1. ●

               Action

               Identify & Treat Precipitants

               Most episodes have identifiable trigger

               • Infection (UTI, SBP, pneumonia) - start antibiotics
               • GI bleeding - treat source
               • Constipation - lactulose
               • Electrolyte disorders (hyponatremia, hypokalemia) - correct
               • Dehydration - IV fluids cautiously
               • Medications (opioids, benzos) - discontinue
               • Dietary protein excess - rare, don't restrict protein
               1. ●

                  Action

                  Lactulose (First-Line)

                  Non-absorbable disaccharide

                  • Initial: 25-45 mL PO q1-2h until bowel movement
                  • Maintenance: 25-45 mL PO BID-QID
                  • Target: 2-3 soft BM/day
                  • Lactulose enema: 300 mL in 1L water (retain 30-60 min)
                  1. ●

                     Action

                     Add Rifaximin (Second-Line)

                     For lactulose failure or recurrence prevention

                     • 550 mg PO BID
                     • Continue lactulose (combination therapy)
                     • Reduces HE recurrence by ~50%
                     • No significant resistance or systemic absorption
                     1. ◆

                        Decision

                        Assess Response

                        Improvement expected within 24-48 hours

                        1. ✓

                           Outcome

                           HE Resolved

                           Continue secondary prophylaxis

                           • Lactulose maintenance (2-3 BM/day)
                           • Rifaximin 550 mg BID after first overt HE episode
                           • Optimize nutrition (1.2-1.5 g/kg protein)
                           • Avoid precipitants
                        2. ⚠

                           Warning

                           Refractory HE

                           Consider additional interventions

                           • Re-evaluate for missed precipitants
                           • Consider TIPS occlusion if post-TIPS HE
                           • Liver transplant evaluation
                           • Zinc supplementation (if deficient)
                           • L-ornithine L-aspartate (LOLA) - limited evidence
         2. ●

            Action

            Grade 2: Disorientation, Lethargy

            Obvious personality change, inappropriate behavior

            • Asterixis present
            • Lactulose + precipitant treatment
            • Consider admission
         3. ⚠

            Warning

            Grade 3: Somnolent, Confused

            Arousable but marked confusion

            • Hospital admission required
            • Lactulose NG if unable to take PO
            • Close monitoring
         4. ⚠

            Warning

            ⚠️ Grade 4: Coma

            ICU admission, consider ALF evaluation

            • Intubate for airway protection
            • Rule out cerebral edema
            • Lactulose enemas if intubated
            • Consider transplant evaluation