Hepatic Encephalopathy (HE)¶
Evaluation¶
- Asterixis: inability to maintain stable posture; many ways to assess
- Check for clonus
- Have pt “hold out hands like you are stopping traffic” (if following commands)
- Shine light in pupil (look up video of hippus)
0 | 1 | 2 | 3 |
---|---|---|---|
Grade | Behavior change | Asterixis | Cerebral Edema in Acute Liver Failure: |
I | Mild confusion, changes in behavior, increased sleep | No Asterixis | No cerebral edema |
II | Moderate confusion, lethargic | Asterixis | Rare cerebral edema |
III | Marked confusion, arousable but falls asleep, incoherent speech | Asterixis | ~30% cerebral edema |
IV | Coma | No Asterixis | ~75% cerebral edema |
- Identify precipitants
- Infection (rule out SBP in addition to CXR, BCx, UA/Cx regardless of sxs),
- Medication non-adherence (lactulose)
- GI bleed (perform rectal exam and observe hgb trend)
- Over-diuresis resulting in dehydration, lyte abnormalities (especially hypoK)
- Sedatives/benzo/opiate administration (UDS)
- Post-TIPS, other large but spontaneous shunt (imaging can be useful to determine if there is a shunt, and if an intervention is feasible on such a shunt).
- Ammonia (NH 3 ) levels do not play a role in the acute management of hepatic encephalopathy; if pt has AMS or HE, you will treat the HE regardless
- Arterial NH 3 is used in acute liver failure for prognostication (not for management)
Management¶
-
Always determine precipitant and treat underlying condition
-
Lactulose 30mL TID initially
- Titrate dose to at least 4 BMs daily, avoid excessive stool output which may exacerbate HE due to dehydration and electrolyte abnormalities
- Consider lactulose enemas vs DHT placement if pt unable to
tolerate PO
- DHT are not contraindicated in patients with esophageal varices, but should be avoided in patients with recent hemorrhage or banding
- Add Rifaximin after the second episode of HE, or if failure to
respond to lactulose
- Frequently requires prior auth for OP approval and is expensive
- Lactulose is generally continued indefinitely after first episode of HE, though discontinuation can be considered if predisposing factors (recurrent infection, EVH, EtOH use) have resolved
Last update:
2022-06-21 02:13:15