Management of hepatic encephalopathy in the hospital

Mayo Clin Proc. 2014 Feb;89(2):241-53. doi: 10.1016/j.mayocp.2013.11.009. Epub 2014 Jan 8.


Hepatic encephalopathy (HE) develops in up to 50% of patients with cirrhosis and is a feature of decompensated cirrhosis. With the goal of reviewing the evidence for treatment and prevention of overt hepatic encephalopathy, pubmed was searched using search terms hepatic encephalopathy AND treatment, limited to human studies from January 1, 2003, through December 1, 2013, and supplemented by key references. The inpatient incidence of HE is approximately 23,000 annually, and management of these patients is common for internists and subspecialists. Treatment of the hospitalized patient with HE has changed in recent years. Treatment entails 2 phases: induction and maintenance of remission. Most cases of significant HE are precipitated by infection, gastrointestinal bleeding, medications, or other culprits. All patients should be evaluated for secondary triggers of HE, and treatment should be initiated with a nonabsorbable disaccharide (ie, lactulose) in most patients. Rifaximin (off label) can be added in patients not responding to lactulose. Neomycin is a less preferred alternative to rifaximin owing to its adverse effect profile. Other therapies, including zinc, L-ornithine-L-aspartate, and branched-chain amino acids, can be considered for patients not responding to disaccharides and nonabsorbable antibiotics. Large portosystemic shunts may be embolized in patients with medically refractory recurrent or severe HE with otherwise well-compensated cirrhosis. Molecular Adsorbent Recirculating System is now available for patients with severe HE who do not respond to medical therapy. It is critically important that patients hospitalized with significant HE continue maintenance therapy at the time of dismissal to prevent further episodes. Patients with a first-time episode of HE can be administered lactulose, and careful instructions should be provided to patients and caregivers about dose titration to achieve 3 bowel movements daily. Patients with recurrent HE episodes despite lactulose use benefit from the addition of rifaximin, which decreases the frequency of recurrent HE episodes and related hospitalizations. Last, patients and their families should be counseled about the risk of motor vehicle accidents, which require mandatory reporting to the Department of Motor Vehicles in some states.

Keywords: BCAA; CHE; CT; EEG; FDA; Food and Drug Administration; HE; LOLA; MARS; MELD; MHE; MVA; Model for End-Stage Liver Disease; Molecular Adsorbent Recirculating System; NG; OHE; RCT; SMT; abx; antibiotic; branched-chain amino acids; computed tomography; covert hepatic encephalopathy; diagnostic; dx; electroencephalogram; hepatic encephalopathy; l-ornithine–l-aspartate; minimal hepatic encephalopathy; motor vehicle accident; nasogastric; overt hepatic encephalopathy; randomized controlled trial; standard medical treatment.

Publication types

  • Review

MeSH terms

  • Disease Management
  • Drug Therapy, Combination
  • Gastrointestinal Agents / therapeutic use*
  • Hepatic Encephalopathy / drug therapy*
  • Humans
  • Inpatients
  • Lactulose / therapeutic use
  • Metronidazole / therapeutic use
  • Neomycin / therapeutic use
  • Protein Synthesis Inhibitors / therapeutic use
  • Recurrence
  • Rifamycins / therapeutic use
  • Rifaximin
  • Terminology as Topic


  • Gastrointestinal Agents
  • Protein Synthesis Inhibitors
  • Rifamycins
  • Metronidazole
  • Lactulose
  • Neomycin
  • Rifaximin