Hepatic Encephalopathy (HE)

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Hepatic encephalopathy (HE) is defined as “a condition which reflects a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction after exclusion of other known  brain disease.” 

Clinical presentation 

Stage Symptoms 

1. Mild confusion, agitation, irritability, sleep disturbance, decreased attention 
2. Lethargy, disorientation, inappropriate behavior, drowsiness 
3. Somnolent but arousable, slurred speech, confused, aggressive 
4. Coma 

Pharmacological Treatment 

S: L-Ornithine L-Aspartate (IV) 10g 8hourly daily for 3-5days 

THEN 

S: L-Ornithine L-Aspartate (PO) 9g 24hourly in divided doses for 4–12weeks 

AND 

C: lactulose solution (PO) for bowel cleansing when required 

Episode of HE (grade 2 or higher)—enemas: 

A:  0.9%  sodium  chloride  300mL  in  1000mL  water  2hourly  until  there  is  clinical improvement 

Episode  of  HE  (able  to  tolerate  oral  administration)—(PO):  45mL  every  hour  until  there  is  bowel  movement and clinical improvement 

Outpatient therapy: 15-45mL 8-12hourly until there are 2-3 bowel movements per day 

AND 

A: metronidazole (PO) 400mg 8 hourly for 7days 

AND  

B: ceftriaxone (IV) 1g 12 hourly for 7days (if evidence of spontaneous bacterial peritonitis) 

Fluid  deficit  correction  and  electrolytes  replacements  as  appropriate  (screen  for  and  correct  all  precipitants of HE as shown in the table below). 

Table 10.2: Precipitants of HE

Hyponatremia	Vomiting
Gastrointestinal bleeding	Diarrhea
Infection	Sedative drugs (narcotics, sleep aids,  antihistaminics)
Surgery	Alkalosis
Dehydration	Azotemia
Fluid restriction	Hypokalemia
Diuretics	Excessive protein intake
Excessive paracentesis	Constipation