I’m confused…

A Review of Hepatic Encephalopathy


  • Overt HE consists of neurological and psychiatric abnormalities that can be detected by
    bedside clinical tests, whereas minimal HE can only be distinguished by specific
    psychometric tests.
  • There are many grading scales available, including the long standing West Haven Criteria,
    which is the most commonly used system.

    • WestHaven Criteria
  • Diagnosis of overt HE requires the exclusion of alternate causes of altered mental status.
  • Serum ammonia levels should not be used as a diagnostic tool or as a means to monitor
    response to treatment.
  • Treatment of acute overt HE should include: 1) supportive care, 2) identifying and treating
    any precipitating factors, 3) reduction of nitrogenous load in the gut, and 4) assessment of
    need for long term therapy and liver transplant evaluation.
  • Lactulose can be used as initial drug therapy for the treatment of acute HE, even in the
    absence of high quality, placebo controlled trials, based on extensive clinical experience
    supporting efficacy. Rifaximin is a reasonable alternative in those who do not respond to
    lactulose alone.
  • Prevention of recurrent HE or treatment of persistent HE includes prevention or avoidance of
    precipitating factors and drug therapy (e.g. lactulose, rifaximin).
  • Protein restriction should be avoided as a general rule, as it can actually lead to worsening of
    HE. Cirrhotic patients are advised to consume 1.0 to 1.5 g/kg protein daily.
  • Liver transplant evaluation should be considered in appropriate candidates once a diagnosis
    of overt HE is made.

HE resistance

From: http://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/hepatic-encephalopathy-diagnosis-management/core-concept/all#summary-points and Z. Poh and P. E. J. Chang, “A Current Review of the Diagnostic and Treatment Strategies of Hepatic Encephalopathy,” International Journal of Hepatology, vol. 2012, Article ID 480309, 10 pages, 2012. doi:10.1155/2012/480309