Hepatic encephalopathyMANAGEMENT

GASTROINTESTINAL PRESENTATIONS · 12 SECTIONS

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540 items

☷ Legend

01Approach to the Critical Patient/attcp59

Immediate priorities

›Stabilization priorities

›If GCS 8 or loss of airway reflexes, intubation

›Head of bed elevation

›Aspiration precautions

›If hypoglycemia, IV dextrose

›Thiamine before dextrose when malnutrition or alcohol use suspected

›Wernicke encephalopathy overlap risk

›If severe agitation, minimal sedatives

›If sedatives required, lowest effective dose

›Avoid long acting benzodiazepines

›If hypotension or shock, balanced crystalloid bolus

›Early vasopressor if persistent hypotension

›Norepinephrine first line for vasodilatory shock

›If fever or suspected sepsis, sepsis bundle activation

›Antibiotics within 1 hour for septic shock

›Source control plan

›HE recognition and risk

›Altered mental status with cirrhosis or portosystemic shunt

›West Haven grade estimation

›Overt HE grades 2 to 4

›Alternative diagnoses treated in parallel

›Intracranial hemorrhage risk with coagulopathy or fall

›If focal deficit, emergent neuroimaging

›Time critical precipitants

›Infection

›SBP risk with ascites

›GI bleeding

›Variceal hemorrhage risk

›Electrolyte derangements

›Hyponatremia

›Sedatives and opioids

›Benzodiazepines

›Constipation

›Reduced stool output

›Dehydration or overdiuresis

›Prerenal azotemia

Hemodynamic and neurologic targets

›Monitoring targets

›Continuous pulse oximetry

›Supplemental oxygen for hypoxemia

›SpO2 target 92 to 96 percent

›Frequent mental status checks

›West Haven trend

›Escalation for worsening grade

›Glucose monitoring

›Capillary glucose goal 4 to 10 mmol/L

›Avoid hypoglycemia

›Temperature monitoring

›Fever triggers infection workup

›Early antimicrobials when unstable

Early consultation triggers

›Team activation

›ICU consult for grade 3 to 4 HE

›Mechanical ventilation requirement

›Vasopressor requirement

›Hepatology consult for recurrent HE or advanced cirrhosis

›Transplant center discussion when eligible

›Acute on chronic liver failure concern

›GI consult for suspected variceal bleeding

›Urgent endoscopy planning

›Hemodynamic instability triggers massive transfusion pathway

02History/hx45

Focused context

›Presentation pattern

›Altered sleep wake cycle

›Day night reversal

›Confusion

›Disorientation

›Personality change

›Irritability

›Somnolence

›Reduced arousal

›Asterixis history

›Difficulty holding objects

Precipitant screen

›Common triggers

›Infection symptoms

›Fever

›Dysuria

›Cough

›GI bleeding clues

›Hematemesis

›Melena

›Constipation

›Stool frequency change

›Diuretic changes

›Recent dose increase

›Volume losses

›Vomiting

›Diarrhea

›Medication and substance exposure

›Benzodiazepines

›Opioids

›Gabapentinoids

›Alcohol

›Recent procedures

›TIPS placement

Baseline liver disease and risk

›Chronic liver disease features

›Known cirrhosis etiology

›Viral hepatitis

›Alcohol associated liver disease

›Prior HE episodes

›Lactulose adherence

›Ascites history

›Prior SBP

›Variceal history

›Prior bleeding

›Baseline functional status

›Ability to perform ADLs

03Physical Exam/exam38

General and neurologic

›Exam domains

›Mental status

›Orientation

›Attention

›Asterixis

›Bilateral wrist extension flap

›Pupils

›Size and reactivity

›Focal deficit screen

›Facial droop

›Pronator drift

›Gait if safe

›Ataxia

Liver disease stigmata and complications

›Cirrhosis findings

›Jaundice

›Scleral icterus

›Fetor hepaticus

›Musty breath odor

›Ascites

›Shifting dullness

›Peripheral edema

›Pitting edema

›Spider angiomata

›Upper trunk distribution

›Bleeding and infection clues

›Melena on rectal exam

›Occult blood positive stool

›Abdominal tenderness

›Peritonitis signs

›Respiratory exam

›Crackles

PITFALLS

›Pitfalls

›Normal asterixis does not exclude HE

›Deep coma without asterixis

›Sedative toxidrome mimic

›Benzodiazepine effect

›Stroke mimic

›Focal deficit mandates alternate diagnosis workup

04Differential Diagnosis/ddx25

Life threats to exclude

›High risk alternatives

›Intracranial hemorrhage

›Anticoagulation exposure

›Ischemic stroke

›Focal deficit

›CNS infection

›Meningitis

›Sepsis associated encephalopathy

›Shock physiology

›Hypoglycemia

›Glucose under 3.0 mmol/L

Common mimics in cirrhosis

›Mimics and coexisting problems

›Alcohol withdrawal

›Tremor

›Wernicke encephalopathy

›Ophthalmoplegia

›Uremic encephalopathy

›Severe azotemia

›Hypercapnia

›COPD history

›Medication toxicity

›Opioid intoxication

Coding alignment

›Coding terms

›Hepatic encephalopathy ICD-10 K76.82

›Consider hepatic failure with coma ICD-10 K72.91 when applicable

05Laboratory Tests/lt61

Core evaluation

›Initial labs

›Glucose

›Hypoglycemia contributor

›Repeat after correction

›Electrolytes

›Sodium mmol/L

›Hyponatremia precipitant

›Potassium mmol/L

›Hypokalemia increases ammonia production

›Bicarbonate mmol/L

›Metabolic alkalosis precipitant

›Renal function

›Creatinine umol/L

›AKI precipitant

›Urea mmol/L

›GI bleed and renal failure markers

›Liver tests

›Bilirubin umol/L

›Severity marker

›INR

›Synthetic dysfunction

›Albumin g/L

›Chronic severity marker

›CBC

›Leukocytosis for infection

›Neutrophilia

›Hemoglobin for bleeding

›Acute drop pattern

›Platelets for portal hypertension

›Thrombocytopenia

Infection workup

›Infection markers and cultures

›Blood cultures

›Fever or shock

›Two sets before antibiotics if feasible

›Urinalysis

›Dysuria or delirium trigger

›Nitrites

›Urine culture

›Pyuria

›Antibiotic tailoring

›Lactate mmol/L

›Sepsis severity

›Trend after resuscitation

Ammonia testing

›Ammonia considerations

›Poor correlation with clinical severity

›Do not use to diagnose in isolation

›ACEP Level C

›If obtained, strict handling

›Rapid processing

›False elevation risk

Other targeted labs

›Additional labs by context

›Venous blood gas

›Hypercapnia screening

›PCO2 mmHg

›Toxicology tests

›Acetaminophen level when overdose possible

›Time sensitive antidote decisions

›TSH when unexplained delirium

›Hypothyroidism mimic

›Alcohol level when unclear history

›Coexisting intoxication

06Diagnostic Tests/dt79

Scoring Systems

›Clinical grading and severity

›West Haven criteria for overt HE

›Grade 0

›No detectable changes

›Grade 1

›Trivial lack of awareness

›Shortened attention span

›Sleep disturbance

›Grade 2

›Lethargy or apathy

›Disorientation for time

›Subtle personality change

›Asterixis

›Grade 3

›Somnolence

›Confusion

›Marked disorientation

›Grade 4

›Coma

›Unresponsive to pain

›Child Pugh for cirrhosis severity

›Bilirubin

›Less than 34 umol/L 1 point

›34 to 50 umol/L 2 points

›Greater than 50 umol/L 3 points

›Albumin

›Greater than 35 g/L 1 point

›28 to 35 g/L 2 points

›Less than 28 g/L 3 points

›INR

›Less than 1.7 1 point

›1.7 to 2.3 2 points

›Greater than 2.3 3 points

›Ascites

›None 1 point

›Mild 2 points

›Moderate to severe 3 points

›Encephalopathy

›None 1 point

›Grade 1 to 2 2 points

›Grade 3 to 4 3 points

›Class A

›Total 5 to 6

›Class B

›Total 7 to 9

›Class C

›Total 10 to 15

MRI

›Neuroimaging MRI role

›Indications

›Persistent altered mental status with negative CT

›Concern for ischemia

›Atypical exam

›Focal deficits

›Limitations

›Time and transport risk

›Unstable patient contraindication

›Limited value for classic overt HE

›Precipitant treatment priority

›Head CT considerations

›Indications

›Fall or head trauma

›Coagulopathy or thrombocytopenia

›Focal neurologic deficit

›Stroke or hemorrhage concern

›New severe headache

›Intracranial bleed concern

›Limitations

›Normal CT does not confirm HE

›Clinical diagnosis remains primary

Ultrasound

›Point of care and abdominal ultrasound

›Ascites assessment

›Large volume ascites supports SBP risk

›Diagnostic paracentesis planning

›Ultrasound guidance

›Paracentesis for suspected SBP

›Safe pocket identification

›Portal vein and shunt context

›TIPS presence confirmation when uncertain

›Recurrent HE risk association

07Disposition/dispo32

Level of care decisions

›Admission criteria

›Overt HE grade 2 to 4

›Inability to ensure lactulose adherence

›Unclear diagnosis

›Neuroimaging or LP consideration

›Suspected infection

›Pending cultures

›Suspected GI bleeding

›Endoscopy planning

›ICU criteria

›Grade 3 to 4 HE

›Airway protection concern

›Respiratory failure

›Hypercapnia

›Shock

›Vasopressor requirement

Transfer and specialty care

›Transfer triggers

›Acute liver failure concern

›Rapidly rising INR

›Transplant evaluation candidate

›Recurrent HE despite therapy

›Variceal bleed without endoscopy capability

›Time sensitive transfer

Discharge criteria

›Discharge only when low risk

›Mental status at baseline

›Reliable caregiver

›Precipitant corrected

›Stable vitals

›Oral intake adequate

›Lactulose plan tolerated

›Rapid follow up arranged

›Hepatology or primary care within 7 days

08Treatment/t91

Core HE therapy

›Ammonia lowering strategy

›Lactulose first line for overt HE

›Class I

›Guideline supported standard therapy

›Rifaximin add on for recurrence prevention

›Class I

›Reduces recurrence and hospitalizations

›Lactulose dosing

›Initial oral or NG

›25 mL to 30 mL every 1 to 2 hours until bowel movement

›Then 15 mL to 30 mL 2 to 4 times daily

›Stool target

›2 to 3 soft stools per day

›Avoid diarrhea and dehydration

›Rectal route when unable to take PO

›300 mL lactulose in 700 mL water as retention enema

›Retain 30 to 60 minutes

›Rifaximin dosing

›550 mg PO twice daily

›Add to lactulose for recurrent HE

›Continue long term in frequent recurrences

Precipitant directed therapy

›Infection management

›Suspected SBP

›Ceftriaxone 2 g IV daily

›Albumin infusion per SBP protocols when indicated

›Suspected UTI

›Antibiotic guided by local resistance

›De escalation after culture

›Suspected pneumonia

›Community acquired coverage per local guidance

›Respiratory support

›GI bleeding management

›Suspected variceal bleed

›Octreotide infusion

›50 microgram IV bolus

›Then 50 microgram per hour infusion

›Ceftriaxone prophylaxis

›1 g IV daily

›PPI therapy

›Pantoprazole 80 mg IV bolus

›Then 8 mg per hour infusion

›Constipation management

›Lactulose titration to stool target

›Add PEG 3350 when refractory constipation

›Avoid dehydration

›Electrolyte and acid base correction

›Hypokalemia correction

›Potassium repletion to normal range

›Reduces renal ammonia generation

›Hyponatremia management

›Avoid rapid correction

›Treat volume status drivers

›Metabolic alkalosis drivers

›Reduce diuretic dose when overdiuresis

›Chloride repletion when indicated

›Medication reconciliation

›Stop benzodiazepines when possible

›Avoid new sedatives

›Class I

›Opioid reduction

›Alternative analgesia plan

›Naloxone when opioid toxicity suspected

›Volume status optimization

›Dehydration

›Balanced crystalloid cautious boluses

›Avoid worsening ascites

›Overdiuresis

›Hold diuretics temporarily

›Renal perfusion support

Adjuncts and special situations

›Flumazenil considerations

›If benzodiazepine effect suspected and airway protected

›0.2 mg IV over 15 seconds

›Repeat 0.2 mg every 1 minute

›Maximum 1 mg

›Seizure risk

›Chronic benzodiazepine use

›Avoid in mixed overdose

›Nutritional considerations

›Avoid routine protein restriction

›Maintain adequate protein intake

›Sarcopenia worsens outcomes

›Thiamine supplementation

›100 mg IV daily for risk patients

›Prevent Wernicke encephalopathy

›Refractory or recurrent HE

›Evaluate TIPS related HE

›Shunt reduction discussion with hepatology

›If medically refractory

›Consider L ornithine L aspartate where available

›Variable guideline support

›Specialist directed

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Oxygenation and perfusion targets

›Fetal monitoring when viable gestation

›Lactulose safety

›Minimal systemic absorption

›Generally compatible with pregnancy

›Infection evaluation

›Lower threshold for sepsis pathway

›Obstetric consultation

Geriatric

›Older adult considerations

›Polypharmacy risk

›Sedatives and opioids common triggers

›Deprescribing plan

›Dehydration susceptibility

›Lactulose induced diarrhea risk

›Close fluid balance monitoring

›Falls risk

›Lower threshold head CT after unwitnessed fall

›Coagulopathy amplifies risk

Pediatrics

›Pediatric considerations

›Different etiologies

›Inborn errors of metabolism

›Hyperammonemia crisis pathways

›Weight based lactulose

›0.5 to 1 mL per kg per dose

›Up to 3 to 4 times daily

›Specialist early involvement

›Pediatric hepatology

›ICU early for worsening mental status

10Background/b38

Epidemiology

›Epidemiology overview

›Common complication of cirrhosis

›Overt HE increases hospitalization risk

›Recurrent episodes common without secondary prophylaxis

›Portosystemic shunts as risk factor

›TIPS increases HE risk

›Highest risk early after placement

Pathophysiology

›Mechanisms

›Ammonia accumulation

›Increased gut production

›GI bleeding protein load

›Reduced hepatic clearance

›Advanced cirrhosis

›Astrocyte dysfunction

›Glutamine osmotic effects

›Cerebral edema risk in severe cases

›Neuroinflammation synergy

›Infection amplifies neurotoxicity

›SBP and sepsis triggers

Therapeutic Considerations

›Therapeutic rationale

›Lactulose mechanism

›Colonic acidification

›Traps ammonium

›Catharsis

›Decreases nitrogen absorption

›Rifaximin mechanism

›Gut microbiome modulation

›Decreases ammonia producing bacteria

›Treatment principle

›Precipitant correction equals primary outcome driver

›Infection and bleeding management

›Evidence framing

›Lactulose for overt HE standard of care

›Class I

›Rifaximin as add on for recurrent HE

›Class I

›Ammonia level not a stand alone diagnostic test

›ACEP Level C

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Discharge instructions

›Lactulose plan

›Dose adjusted to 2 to 3 soft stools per day

›Hold and call clinic if severe diarrhea

›Medication safety

›Avoid alcohol

›Avoid benzodiazepines unless prescribed by liver specialist

›Avoid new sedating medicines

›Check with pharmacist or clinician first

›Hydration plan

›Drink fluids unless fluid restriction prescribed

›Monitor for dizziness or low urine output

›Return to ED now for

›Worsening confusion

›Unable to stay awake

›Fever

›Shaking chills

›Vomiting blood

›Black tarry stools

›New severe headache

›Weakness or numbness on one side

›Shortness of breath

›Chest pain

›Follow up

›Liver clinic or family doctor within 7 days

›Earlier if symptoms recur

›Caregiver plan

›Do not drive until cleared

›Reliable adult supervision for 24 to 48 hours

12References/r13

Clinical guidelines and evidence

›Guideline and key evidence sources

›AASLD EASL Practice Guideline on hepatic encephalopathy in chronic liver disease

›Lactulose first line for overt HE

›Rifaximin add on for recurrent HE

›EASL clinical practice guidance on decompensated cirrhosis

›Precipitant evaluation emphasis

›Avoid unnecessary protein restriction

›Major randomized trials of rifaximin for HE recurrence prevention

›Reduced breakthrough HE episodes

›Reduced HE related hospitalization

›Society guidance on SBP evaluation in cirrhosis with altered mental status

›Diagnostic paracentesis when ascites present

›Early empiric antibiotics when unstable

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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