Category: Critical Care
Keywords: Hepatic encephalopathy, HE, liver failure, cirrhosis (PubMed Search)
Posted: 12/17/2013 by Feras Khan, MD
(Updated: 4/25/2024)
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Hepatic Encephalopathy (HE)
Pathogenesis: Several theories exist that include accumulation of ammonia from the gut because of impaired hepatic clearance that can lead to accumulation of glutamine in brain astrocytes leading to swelling in patients with hepatic insufficiency from acute liver failure or cirrhosis.
Clinical Features:
Diagnostic tests: Ammonia levels are routinely drawn but must be drawn correctly without the use of a tourniquet, transported on ice, and analyzed within 20 minutes to get an accurate result. Severity of HE does not correlate with increasing levels.
Management:
1. Airway protection as needed
2. Correct precipitating factors (GI bleed, infection-SBP, hypovolemia, renal failure)
3. Consider neuro-imaging if new focal neurologic findings are found on exam
4. Correct electrolyte imbalances
5. Lactulose by mouth (PO/Naso-gastric tube or Rectally)
a. 10-30 g every 1-2 hours until bowel movement or lactulose enema (300 mL in 1 L water)
b. Facilitates conversion of NH3 to NH4+, decreases survival of urease-producing bacteria in the gut
6. Rifaximin 550 mg by mouth BID (minimally absorbed antibiotic with broad-spectrum activity)
7. Do not limit protein intake acutely
8. TIPS reduction in certain patients with recurrent HE
9. Transplant referral as needed
10. Consider other causes if patient does not improve within 24-48hrs.
Med Clin North Am. 2014 Jan;98(1):119-52. doi: 10.1016/j.mcna.2013.09.006. Epub 2013 Oct 30.
Management of End-stage Liver Disease.
