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Latest Concepts in Inpatient Hepatic Encephalopathy Management

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Diagnosis and Management of Hepatic Encephalopathy

Abstract

Hepatic encephalopathy (HE), a common complication in patients with decompensated cirrhosis, significantly impacts quality of life and also survival. Current nomenclature recognizes type A HE (acute liver failure), type B (portosystemic shunts absent liver disease), and type C (liver disease). Recently, it has been observed that HE is an additional risk factor for death in patients with acute-on-chronic liver failure (ACLF). Thus, it has been proposed that HE in the setting of ACLF be considered a separate entity and that there may be important subtypes, namely isolated HE (without extrahepatic organ failure) and HE-associated ACLF (with extrahepatic organ failure), that carry different prognoses. The mechanism of the latter is not well known but thought to be from the combination of hyperammonemia and systemic inflammation. The confirmation of HE diagnosis requires exclusion of other possible causes. Precipitating factors of HE must be treated if they are identified. Early detection of extrahepatic organ failure is vital for risk stratification purposes and to determine the need for organ support. Specific HE treatment should be initiated with a nonabsorbable disaccharide (i.e., lactulose) in most cases. Rifaximin can be added in patients not responding to lactulose. Other treatments including zinc, l-ornithine l-aspartate, branched-chain amino acids, and molecular adsorbent recirculating system (MARS) can be considered in refractory HE. If technically feasible, large portosystemic shunts may be embolized. Ultimately, liver transplant is the most definitive treatment option for HE, especially in the setting of ACLF. However, current organ allocation system does not take HE into account and active infection in ACLF can be a contraindication for liver transplant.

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Abbreviations

ACLF:

Acute-on-chronic liver failure

BCAA:

Branched-chain amino acids

CLIF-C ACLF:

Chronic Liver Failure Consortium ACLF Score

DAMPs:

Damage-associated molecular patterns

ESPEN:

European Society for Parenteral and Enteral Nutrition

FDA:

Food and Drug Administration

HE:

Hepatic encephalopathy

IL:

Interleukin

LOLA:

l-ornithine l-aspartate

LT:

Liver transplant

MARS:

Molecular adsorbent recirculating system

MELD:

Model for end-stage liver disease

PAMPs:

Pathogen-associated molecular patterns

RCT:

Randomized controlled trial

TIPS:

Transjugular intrahepatic portosystemic shunt

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA

    Thoetchai (Bee) Peeraphatdit M.D., Patrick S. Kamath M.D. & Michael D. Leise M.D.

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  1. Thoetchai (Bee) Peeraphatdit M.D.
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  2. Patrick S. Kamath M.D.
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  3. Michael D. Leise M.D.
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Correspondence to Patrick S. Kamath M.D. .

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Editors and Affiliations

  1. McGuire VA Medical Center, Virginia Commonwealth University, Richmond, Virginia, USA

    Jasmohan S. Bajaj

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Peeraphatdit, T.(., Kamath, P.S., Leise, M.D. (2018). Latest Concepts in Inpatient Hepatic Encephalopathy Management. In: Bajaj, J. (eds) Diagnosis and Management of Hepatic Encephalopathy. Springer, Cham. https://doi.org/10.1007/978-3-319-76798-7_6

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  • DOI: https://doi.org/10.1007/978-3-319-76798-7_6

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