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

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

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

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

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

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

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

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

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

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

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 August 18, 2026

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