Critical Alerts

• Must identify and treat precipitants: Infection (SBP), GI bleed, constipation, medications
• Ammonia level doesn't correlate with severity: Clinical assessment is paramount
• Risk of cerebral edema in acute liver failure: Different from chronic HE
• Differentiate from other causes of AMS: Infection, intoxication, stroke, hypoglycemia
• Lactulose is first-line treatment: Goal is 2-3 soft stools daily
• Check for infection: SBP is common precipitant in cirrhosis

Key Diagnostics

Emergency Treatments

Overview

Hepatic encephalopathy (HE) is a spectrum of neuropsychiatric abnormalities occurring in patients with liver dysfunction, resulting from the accumulation of neurotoxins (primarily ammonia) that bypass hepatic metabolism. It ranges from subtle cognitive changes to deep coma and is usually precipitated by identifiable factors in patients with chronic liver disease.

Classification

By Type:

By Severity (West Haven Criteria):

By Course:

• Episodic: Single episode with precipitant
• Recurrent: Multiple episodes within 6 months
• Persistent: Persistent cognitive impairment despite treatment

Epidemiology

• Prevalence in cirrhosis: 30-45% will have overt HE at some point
• Minimal HE: Present in 20-80% of cirrhotics (often undiagnosed)
• Hospital readmissions: HE is leading cause of readmission in cirrhosis
• Mortality: 30-50% 1-year mortality after first episode of overt HE

Etiology

Precipitating Factors (Most Important to Identify):

Life-Threatening Conditions

Alternative Diagnoses to Consider

• Alcohol intoxication or withdrawal
• Hypoglycemia
• Infection/Sepsis (causing delirium)
• Stroke
• Subdural hematoma (especially if falls or anticoagulation)
• Medication overdose
• Wernicke's encephalopathy
• Uremia

AMS in Patients with Cirrhosis

Clinical Diagnosis

HE is a clinical diagnosis based on:

1. Known liver disease or portal-systemic shunting
2. Altered mental status (ranging from subtle to coma)
3. Exclusion of other causes of AMS
4. Identification of precipitant (if possible)

Laboratory Studies

Ammonia Interpretation:

• Elevated ammonia supports but does not confirm diagnosis
• Normal ammonia does not exclude HE
• Single values less useful than trends
• Do not use to titrate therapy

Diagnostic Paracentesis

Indications in HE:

• Any patient with ascites and AMS (to rule out SBP)
• Fever, abdominal pain, or tenderness

SBP Criteria:

• PMN count ≥250 cells/μL = SBP (treat empirically)
• Culture positive (may be delayed)

Imaging

CT Head:

• Not routinely needed for classic HE presentation
• Indicated if: Focal signs, head trauma, anticoagulated, atypical presentation
• Rule out stroke, SDH, other structural causes

Psychometric Testing (For Minimal HE)

• Number connection test
• Digit symbol test
• Critical flicker frequency
• Not practical in acute setting

Admission Criteria

• Grade II or higher HE (overt HE)
• Any HE with identified precipitant requiring treatment (GI bleed, SBP)
• Unable to take oral medications
• Inadequate home support
• Failure of outpatient management

ICU Criteria

• Grade III-IV HE with airway concerns
• Acute liver failure with HE
• Concurrent GI bleeding or septic shock
• Need for intubation

Discharge Criteria

• Mental status returned to baseline
• Precipitant treated
• Tolerating PO lactulose
• Adequate home support
• Follow-up arranged with hepatology

Follow-Up

Condition Explanation

• "Your liver is not able to remove toxins from your blood effectively, and these toxins are affecting your brain."
• "This is treatable, but we need to find out what triggered this episode."
• "Lactulose works by helping your body get rid of these toxins through bowel movements."

Medication Instructions

Lactulose:

• Take as prescribed; do not stop without physician guidance
• Goal is 2-3 soft bowel movements per day
• Too few = underdose → confusion may return
• Too many = dehydration → confusion may worsen
• Sweet taste; can mix with juice
• If you can't take it orally, seek medical attention

Rifaximin:

• Take twice daily with or without food
• Prevents recurrence of confusion
• May be expensive; ask about patient assistance programs

Prevention Strategies

• Avoid constipation
• Stay hydrated
• Avoid sedatives, sleeping pills without physician approval
• Avoid excessive salt intake (worsens fluid retention)
• Maintain good nutrition
• Avoid alcohol completely
• Take medications as prescribed

Warning Signs Requiring Medical Attention

• Worsening confusion
• Increased sleepiness
• Blood in stool or vomiting blood
• Fever
• Abdominal pain or increased swelling
• Unable to take medications
• Falls

Acute Liver Failure (Type A HE)

• Different pathophysiology: Cerebral edema and elevated ICP are major concerns
• Requires ICU-level care
• ICP monitoring may be needed
• Consider mannitol or hypertonic saline for elevated ICP
• Liver transplant evaluation urgently
• Lactulose is still used but managing ICP is critical

Post-TIPS

• HE is a known complication of TIPS
• Occurs in 30-50% of patients
• May require TIPS reduction or embolization
• Manage with lactulose and rifaximin

Minimal Hepatic Encephalopathy

• Subclinical cognitive impairment
• May affect driving, work performance
• Treat with lactulose; rifaximin if needed
• Specialist follow-up

Elderly

• Higher mortality
• More likely to have medication precipitants
• Falls are common
• May need more support at home

Performance Indicators

Documentation Requirements

• Mental status using standard grading
• Precipitant(s) identified or "unknown"
• Lactulose dosing and patient response
• Paracentesis results if performed
• Ammonia level (if obtained)
• Alternative diagnoses considered and excluded
• Discharge plan including medication instructions

Diagnostic Pearls

• HE is a clinical diagnosis: Ammonia level doesn't define or grade severity
• Always look for the precipitant: Treatment won't work without addressing it
• Paracentesis is mandatory: If ascites + AMS, rule out SBP
• Asterixis is not unique to HE: Also seen in uremia, hypoxia, sedatives
• Normal ammonia doesn't exclude HE: Clinical assessment is paramount
• Consider other diagnoses: Especially in cirrhosis (SDH from falls, intoxication)

Treatment Pearls

• Lactulose goal is 2-3 soft stools: Titrate accordingly
• Rectal lactulose works: If patient can't take PO
• Don't protein restrict: Actually harmful; maintain nutrition
• Rifaximin reduces recurrence: Consider adding for recurrent HE
• Treat the precipitant: Antibiotics for SBP, GI bleed management, etc.
• Avoid sedatives: Benzodiazepines worsen HE

Disposition Pearls

• Admit all overt HE (Grade II+): Need hospital management
• Transplant evaluation for recurrent: May be only cure
• Education is essential: Medication compliance prevents recurrence
• Family involvement: Patients may not recognize early symptoms