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• W1752204734 abstract "Watch a video presentation of this article Answer questions and earn CME This review is limited to the management of inpatients with clinically overt hepatic encephalopathy (HE) due to cirrhosis.1 Type C overt HE should be divided into episodic HE (when the symptoms develop over a short period and fluctuate in severity), recurrent HE (characterized by bouts of HE within a time interval of 6 months or less), or persistent HE (with continuous behavioral or neurological symptoms). Another important distinction is between spontaneous and precipitated HE, the latter induced by a specific and clearly identifiable precipitating event, as those reported in Table 1.1 The above taxonomy of overt HE (episodic versus recurrent versus persistent, precipitated versus spontaneously occurring) is clinically relevant because the diagnostic procedures and management of each category differ. Once the diagnosis of overt HE is made, every effort should be made to identify the precipitating cause. In fact, although not evaluated by specific randomized, controlled trials (RCTs), the rapid identification of a the precipitant is considered the first line in managing patients with this type of HE, and its correction is essential for the resolution of symptoms. Multiple precipitating events frequently may coexist in the same patient. For example, a patient with HE precipitated by a gastrointestinal (GI) bleeding may also have severe anaemia, hypovolemia, and functional renal failure. Moreover, infections such as a spontaneous bacterial peritonitis (SBP) may develop after GI bleeding, and this new event, if not promptly recognized, may contribute to the persistence of the neurological abnormalities. A well-known clinical rule is to search for any additional precipitant if the neurological symptoms do not ameliorate once the inciting precipitating event has resolved. The workup given in Table 3 may be useful and should be repeated when the resolution of HE does not follow the resolution of the initial precipitating event. Although the true prevalence of precipitants is not very well known, it is very likely that infections represent the most common precipitating event in the current series of patients.3 Therefore, in all patients with HE, it is mandatory to perform a careful search for a bacterial infection. Although most of the infectious episodes are clearly evident, others, such as SBP, require a specific diagnostic procedure to be detected (Table 2). The search for an occult infection is also mandatory in patients with recurrent HE and even in those with persistent HE. In patients with continuous or frequently recurrent HE symptoms, it is also important to search for the presence of large porto-systemic shunt,4 which may be suitable for occlusion.5 This therapeutic opportunity, as well as the possibility of the reducing the diameter of a too-large stent in patients who have undergone transhepatic intrahepatic portosystemic shunt placement,6 has to be considered, especially in patients with preserved liver function. The general supportive care of a patient hospitalized because of overt HE is reported in Table 4, which also summarize the main management of the precipitating events. The decision to maintain the patient in the general ward or in intensive care depends not only on the severity of HE, but also on the severity of and the number of precipitating events present at the same time and whether the patient is at risk or unable to protect his or her airway. The care of the patient's nutritional status is also considered useful. Energy intake of 35–40 kcal/kg body weight/day and protein intake of 1.2-1.5 g/kg body weight/day are recommended.7 A recent RCT clearly showed that the reduction of protein intake in patients with overt HE is unnecessary for the resolution of symptoms and may further contribute to the patient's malnutrition.8 An RCT compared the use of the molecular absorbent recirculating system (MARS), a method of hemodiafiltration with standard medical treatment (SMT) in patients with severe (grades III-IV) HE. Seventy-two percent of the patients responded in the MARS group compared with 40% in the SMT group (not significant). None of the surviving patients whose HE improved by two stages returned to their prestudy HE grade during the 5-day study period, and mortality was not reduced by MARS. Thus, overall, there was no significant benefit of MARS in these patients.9 As 90% of patients hospitalized for episodic overt HE respond to the above general measures and to the treatment of the precipitating event, the use of drugs such nonabsorbable disaccharide, low-absorbable antibiotics, l-ornitine-l-aspartate, branched-chain amino acids, and benzodiazepine antagonists remain a matter of discussion.10 The clinical problem once HE is reversed is to determine how to prevent its recurrence. Recent RCTs showed that this goal could be obtained by the administration of lactulose,11 rifaximin, or a combination of both.12" @default.
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• W1752204734 date "2015-03-01" @default.
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• W1752204734 title "Management of hepatic encephalopathy as an inpatient" @default.
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• W1752204734 doi "https://doi.org/10.1002/cld.457" @default.
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