Liver Capsule: HEPATIC ENCEPHALOPATHY
Subdivided by Time course: episodic (one epidose/6 months), recurrent: >1/6 months, persistent—never resolved Factor-associated: precipitated (associated factors), spontaneous (none))
HEPATIC ENCEPHALOPATHY (HE) COVERT HE OVERT HE Includes minimal HE and grade 1 HE
Diagnosis
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Exclusion of other causes of altered mental status Obvious clinical manifestations ranging from disorientation through coma without focal deficits
In-hospital death, aspiration, recurrent episodes, disability, burden on caregivers and socioeconomic status, poor survival within 2 years of discharge, persistent cognitive impairment after multiple episodes
Cannot be diagnosed clinically Needs combination of paper/pencil/ computerized/neurophysiological tests
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Treatment strategies
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Acute episode: care of unconscious patient, identify/treat precipitating factors, and empiric treatment with lactulose, then rifaximin To prevent recurrence: after first episode, lactulose; after second episode, rifaximin Overall: consideration for liver transplantation
Clinical relevance
Growing evidence base but not standard care Can treat patients on an individual basis with lactulose, rifaximin, or probiotics
Overt HE development, impaired quality of life Driving and socioeconomic status Higher death and hospitalizations
Patients can change between these states over time
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA. [email protected]
Jasmohan S. Bajaj
References 1. Wright G, Noiret L, Olde Damink SW, Jalan R. Interorgan ammonia metabolism in liver failure: the basis of current and future therapies. Liver Int 2011;31:163-175. 2. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. HEPATOLOGY 2014;60:715-735. 3. Bajaj JS, Cordoba J, Mullen KD, Amodio P, Shawcross DL, Butterworth RF, et al. Review article: the design of clinical trials in hepatic encephalopathy—an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement. Aliment Pharmacol Ther 2011;33:739-747. 4. Butterworth RF. Hepatic encephalopathy: a central neuroinflammatory disorder? HEPATOLOGY 2011;53:1372-1376. 5. Bajaj JS, Heuman DM, Hylemon PB, Sanyal AJ, White MB, Monteith P, et al. Altered profile of human gut microbiome is associated with cirrhosis and its complications. J Hepatol 2014;60:940-947. Received June 30, 2015; accepted July 3, 2015. DOI 10.1002/hep.27984 Potential conflict of interest: Nothing to report Copyright ©2015 by the American Association for the Study of the Liver Diseases.
Subdivided by Time course: episodic (one epidose/6 months), recurrent: >1/6 months, persistent—never resolved Factor-associated: precipitated (associated factors), spontaneous (none))
HEPATIC ENCEPHALOPATHY (HE) COVERT HE OVERT HE Includes minimal HE and grade 1 HE
Diagnosis
• •
Exclusion of other causes of altered mental status Obvious clinical manifestations ranging from disorientation through coma without focal deficits
In-hospital death, aspiration, recurrent episodes, disability, burden on caregivers and socioeconomic status, poor survival within 2 years of discharge, persistent cognitive impairment after multiple episodes
Cannot be diagnosed clinically Needs combination of paper/pencil/ computerized/neurophysiological tests
•
•
• •
• •
Treatment strategies
•
Acute episode: care of unconscious patient, identify/treat precipitating factors, and empiric treatment with lactulose, then rifaximin To prevent recurrence: after first episode, lactulose; after second episode, rifaximin Overall: consideration for liver transplantation
Clinical relevance
Growing evidence base but not standard care Can treat patients on an individual basis with lactulose, rifaximin, or probiotics
Overt HE development, impaired quality of life Driving and socioeconomic status Higher death and hospitalizations
Patients can change between these states over time
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA. [email protected]
Jasmohan S. Bajaj
References 1. Wright G, Noiret L, Olde Damink SW, Jalan R. Interorgan ammonia metabolism in liver failure: the basis of current and future therapies. Liver Int 2011;31:163-175. 2. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. HEPATOLOGY 2014;60:715-735. 3. Bajaj JS, Cordoba J, Mullen KD, Amodio P, Shawcross DL, Butterworth RF, et al. Review article: the design of clinical trials in hepatic encephalopathy—an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement. Aliment Pharmacol Ther 2011;33:739-747. 4. Butterworth RF. Hepatic encephalopathy: a central neuroinflammatory disorder? HEPATOLOGY 2011;53:1372-1376. 5. Bajaj JS, Heuman DM, Hylemon PB, Sanyal AJ, White MB, Monteith P, et al. Altered profile of human gut microbiome is associated with cirrhosis and its complications. J Hepatol 2014;60:940-947. Received June 30, 2015; accepted July 3, 2015. DOI 10.1002/hep.27984 Potential conflict of interest: Nothing to report Copyright ©2015 by the American Association for the Study of the Liver Diseases.
