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Hepatic Encephalopathy (HE)


  • 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)


  • 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