Hepatic Encephalopathy

Hepatic Encephalopathy


  • 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)
    • place pt in “frog leg” position and observe for flapping movement
    • check for pupillary changes which may herald increased ICP (helpful in ICU)



Behavior change


Cerebral Edema in

Acute Liver Failure:


Mild confusion, changes in behavior, increased sleep

No Asterixis

No cerebral edema


Moderate confusion, lethargic


Rare cerebral edema


Marked confusion, arousable but falls asleep, incoherent speech


~30% cerebral edema



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 (NH3) 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 NH3 is used in acute liver failure for prognostication (not for management)



  • Always determine precipitant and treat underlying condition
  • If GCS <8 (grade III/IV) transfer to MICU for intubation for airway protection. Consider discussing with fellow early in course if failing to respond mgmt below
  • 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
      • Golytely can be substituted for lactulose with DHT in and can halve the time to recovery
    • 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
      • Branched chain amino acids (0.25 gm/kg/day, available at Walmart) can be considered if unable to take rifaximin and recurrent HE (should discuss this w/ attending/fellow)
      • Rifaximin should be used for primary ppx of HE before and following TIPS
      • Recurrent HE after TIPS:  should investigate and consider TIPS constrainment
  • 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
  • Beware bowel mgmt systems in pts with severe portal HTN and place only if necessary
    • Can disrupt rectal varices and lead to hemorrhage. D/w attending