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2437 pages added, reviewed or updated during the last month (last updated: 22/4/2021)

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management of hepatic encephalopathy

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Management of HE differ according to its type and severity.

  • patients with covert HE usually do not require treatment except in cases where the condition is thought to be adversely affecting quality of life
  • once grade 3 or 4 encephalopathy develops, there is a high risk of cerebral oedema and multiorgan failure.

Appropriate treatment overt HE will result in shorter episodes and will also prevent further episodes

  • first step in management of acute patients is to address underlying precipitants of encephalopathy - such as hypoglycaemia, hypoxia, haemorrhage, sepsis, drug toxicity, or electrolyte disturbance, should be corrected.


  • although dietary protein withdrawal is advised, a small randomised trial reported that normal protein diets are safe, and protein malnutrition may contribute to sarcopenia, potentially worsening the condition.
  • the International Society for Hepatic Encephalopathy and Nitrogen Metabolism recommends that 1.2-1.5 g/kg of protein can be given in small meals distributed throughout the day, with a late night snack of complex carbohydrates
  • nasogastric tube should be considered if above dietary target cannot be achieved

Non-absorbable disaccharides and probiotics

  • Lactulose (a non-absorbable disaccharide) helps in reducing pH and excretion of ammonia as well as the utilisation of ammonia in the metabolism of gut bacteria
    • EASL-AASLD guidelines recommends that lactulose should be used as the first line agent in the management of overt HE and then to continue in order to prevent further episodes
    • dose - 25 mL of lactulose twice daily aiming to achieve three soft bowel motions a day
  • probiotic therapy
    • has been shown to decrease overt hepatic encephalopathy
    • can be given as yoghurt drinks or tablets, commonly containing Lactobacillus rhamnosusand Saccharomyces boulardii
  • polyethylene glycol
    • has been shown to be as effective as, and possibly superior to, lactulose in terms of speed of resolution of hepatic encephalopathy and reduction in length of hospital stay

Neomycin and rifaximin

  • neomycin
    • was the first antibiotic agent to be widely used in HE
    • is not used routinely in clinical practice because of the significant toxicity associated with its long-term use
  • rifaximin
    • is recommended, within its marketing authorisation, as an option for reducing the recurrence of episodes of overt hepatic encephalopathy in people aged 18 years or older
    • a semi-synthetic derivative of the antibiotic rifamycin
    • decreases intestinal production and absorption of ammonia, which is thought to be responsible for the neurocognitive symptoms of hepatic encephalopathy, thereby delaying the recurrence of acute episodes (1,2)

Sedation should be avoided so that there is no masking of the level of consciousness


Last reviewed 01/2018