Management of hepatic encephalopathy

Hepatic encephalopathy (HE), the neuropsychiatric presentation of liver disease, is associated with high morbidity and mortality. 

The reduction of plasma ammonia remains the central therapeutic strategy.

It is very important to rule out an alternative diagnosis. 

Invariably  Hepatic encephalopathy is found in known or suspected CLD presenting with altered sensorium but if there is suspicion of neurological disease get a CT scan done.

Further, in doubt get Arterial NH₃  levels  

>75ug/dl is associated with Hepatic encephalopathy  

and >200ug/dl is associated with cerebral herniation,

Initial workup

·      Hemogram RFT,LFT,INR, Sugar, ECG ·      USG abdomen   ·      Brain imaging in relevant cases

GRADES OF HEPATIC ENCEPHALOPATHY  Click to calculate Hepatic encephalopathy grades

Management

·      Grade I/II HE ·      Identify cerebral edema, avoid sedation   ·      Syp. Lactulose  (15-30ml) 6hrly OR Lactulose bowel wash (200ml in 800ml of water) ·      Tab.Rifaximin 400mg 8hrly ·      Grade III/IV HE         Continue above , elevate head of bed 300 May need Intubation ·      ICP monitoring  Treatment of cerebral edema ·      Goal -ICP<20MMhG ·      IV Mannitol 20%, 100ml TDS if there is no renal failure ·      Correct Hyponatremia  145-155mmol/L