Hepatic Encephalopathy

Overview

  • Assess for and treat precipitants of hepatic encephalopathy
  • Minimize/avoid opioids, sedatives, and proton pump inhibitors
  • Add Rifaximin with lactulose intolerance or with the second episode of overt hepatic encephalopathy. To date, the largest studies have evaluated the efficacy of Rifaximin in combination with lactulose
  • There is NO role for protein restriction in hepatic encephalopathy
  • Do not order serum ammonia to diagnose or manage hepatic encephalopathy (Choosing Wisely Canada)
  • Tools to grade severity of hepatic encephalopathy
  • Consider differential diagnoses*
    • D - Drugs/toxins
    • I  -  Infection – primary CNS or alternate site
    • M - Metabolic – glucose, sodium, calcium, thyroid, CO2, O2 abnormalities
    • S -  Structural – primary CNS – tumor, hemorrhage, edema, seizure, underlying dementia
    • O - Other – psychiatric disease, shock

* Many of these causes can also precipitate hepatic encephalopathy

Identify and treat acute precipitants

  • Lack of compliance with Lactulose, Rifaximin
  • Do not assume that hepatic encephalopathy is the result of non-compliance to Lactulose or Rifaximin before ruling out other precipitants
  • Constipation
  • Medications: these medications should be used with caution in hepatic encephalopathy
    • Opioids
      • Opioids can worsen hepatic encephalopathy due to sedation and constipation
      • Minimize / wean with the goal of stopping if possible
      • Consider alternatives, i.e. regular acetaminophen (can be used to a maximum of 2000 mg per day) to help lower opioid dosing
      • Consider an extra lactulose dose per day with re-titration to 2-3 soft, formed bowel movements at initiation or increase of opioid/sedative medications
    • GABAergics, sedatives and anxiolytics including benzodiazepines
      • Minimize and avoid use if possible
    • Proton pump inhibitors (PPI)
      • There is an association between PPI use and overt hepatic encephalopathy, potentially related to alterations in gut flora
      • Reassess the indication for regular PPI use. Most people on PPI do not have a chronic need or indication
      • If possible, dose reduce or stop the PPI. Start with reducing from twice daily dosing, to daily, to discontinuation, if no return of symptoms. If return of GI symptoms, then consider intermittent PPI use at the lowest dose possible or a trial of a different drug class (e.g. H2 antagonists)
  • Infection even if no clear signs on vitals or blood work:
    • Blood culture, urine culture, and chest x-ray
    • Paracentesis if ascites present
  • GI Bleeding
  • Metabolic abnormalities including kidney injury, hypokalemia, dehydration, hypoxia
  • Diuretics – in some cases, these may be the only precipitant, even in the absence of metabolic abnormalities

 

 

General Principles

  • Ensure nutrition targets are being met – there is NO need to restrict protein in people with hepatic encephalopathy
  • Sarcopenia worsens with hepatic encephalopathy as skeletal muscle is an important organ for detoxifying ammonia. All patients should be given nutrition education and a target range for protein intake (1.2-1.5g/kg/day). Encourage protein intake from a variety of sources including dairy and vegetable protein

General Principles

  • This patient has decompensated cirrhosis. Consider discussion with a liver specialist for management advice and potential transplant consideration
  • Determine if safe/able to tolerate oral intake
  • Initiate empiric therapy for overt hepatic encephalopathy

 

If oral intake safe/tolerated

  • Lactulose 30 mLs PO Q1-2H until bowel movement or clinical improvement

If oral intake not safe/not tolerated

  • Lactulose 45 mLs NG Q1-2H until bowel movement or clinical improvement

If improvement start secondary prophylaxis

  • Lactulose 15-30 mLs orally twice a day (titrate to achieve 2-3 soft bowel movements per day)

AND

  • Rifaximin 550 mg orally twice a day*

* Reduces recurrent hepatic encephalopathy and hospitalizations; consider it with lactulose intolerance, recurrent (> 1 episode), or persistent hepatic encephalopathy despite lactulose therapy)

If no improvement

  • Start Rifaximin 550 mg orally twice a day
  • Look for causes of Refractory HE. This should be done in conjunction with a liver specialist. The differential diagnosis includes:
    • Failure to identify a common precipitant (reconsider whether any of the listed precipitants under general management including diuretics may be contributing)
    • Profound zinc deficiency
    • Other causes of altered mental status
    • Transjugular portosystemic shunt (TIPS) or spontaneous portosystemic shunts (see more details below)
    • TIPS reduction: can be considered after consultation with a liver specialist about the risks and benefits. If non-selective b-blockers were needed for variceal prophylaxis before the TIPS, they will be required after TIPS reduction

Cirrhosis Care  Tools to grade severity of hepatic encephalopathy

Cirrhosis Care The Nutrition in Cirrhosis Guide

Cirrhosis Care Alberta