Hepatic encephalopathy – recent advances in treatment and diagnosis

ABSTRACT

Introduction

Hepatic encephalopathy (HE) is a peculiar kind of brain dysfunction typical of liver cirrhosis characterized by nonspecific neurological and psychiatric manifestations. HE ranges from minimal hepatic encephalopathy (MHE) to the most severe form characterized by alteration of consciousness or coma (overt HE, OHE). Once the diagnosis of OHE is made, every effort to identify and correct the precipitating cause is essential for the resolution of symptoms. Clinical studies that assessed the prevalence and incidence of any type of HE (MHE and OHE) in patients affected by cirrhosis were included in this review. No language, publication date, or publication status restrictions were imposed. The studies were identified by searching electronic databases (PubMed and SCOPUS).

Areas covered

The most widely empirical pharmacological approach consists of non-absorbable antibiotics (rifaximin) and non-absorbable disaccharides (lactulose, lactitol per os and per enemas). Other agents (including branched-chain amino acids, probiotics, other antibiotics, or intravenous L-ornithine L-aspartate) are available, but the evidence supporting their efficacy remains under debate.

Expert opinion

Gray areas and future needs remain the therapeutic approach to MHE and issues in the design of therapeutic studies for HE which have been extensively discussed in this review.

KEYWORDS:

• Overt hepatic encephalopathy
• minimal hepatic encephalopathy
• sarcopenia
• portosystemic shunts
• ammonia
• liver cirrhosis

Article highlights

• Hepatic encephalopathy occurs in up to 45% of patients affected by liver cirrhosis.

• Depending on the clinical manifestation, HE can be divided into a subclinical form of HE, called now ‘covert’ HE, and in a clinically evident form of HE, called ‘overt’ HE.

• The diagnosis of overt HE is not always immediate because HE can be overlapped with other medical, neurological, and psychiatric conditions causing brain dysfunction (differential diagnosis).

• Pharmacological approach consists of non-absorbable antibiotics (rifaximin) and non-absorbable disaccharides (lactulose, lactitol per os and per enemas).

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.