Hepatic encephalopathy is a brain dysfunction caused by liver disease or portosystemic shunting. It presents as a wide range of neurological or psychiatric abnormalities from mild alterations to coma. The prevalence is 30-40% in those with cirrhosis and risk of first episode is 5-25% within 5 years of cirrhosis diagnosis. Recurrence risk after an initial episode is 40% within 1 year. Ammonia, systemic inflammation, manganese, genetics, and oxidative stress may all contribute to pathogenesis. Diagnosis involves clinical exam and testing like serum ammonia levels or neuropsychological tests on phone apps. Management involves treating precipitating factors, lactulose, antibiotics like rifaximin, and

1. Hepatic EncephalopathyHepatic Encephalopathy
Dr.Santosh M Narayankar
Department Of Gastroenterology
Yashoda Hospital

2. Definition
Hepatic encephalopathy is a brain
dysfunction caused by liver insufficiency
and/or PSS
It manifests as a wide spectrum of
neurological or psychiatric abnormalities
ranging from subclinical alterations to
coma.
Reversible impairment of neuropsychiatric
function.

3. Prevalence
• Overall: 30%–40% of those with cirrhosis at some
time during their clinical course.
• The prevalence of OHE at the time of diagnosis of
cirrhosis is 10%–14% in general.
• In decompensated cirrhosis is 16–21%.
• After TIPS: 10-50%.
• CHE: 20-80%.
• The risk for the first bout of OHE is 5%–25% within 5 years
after cirrhosis diagnosis.
• Recurrence:
• 40% within 1st year after index OHE.
• Recurrent OHE have a 40% cumulative risk of another
recurrence within 6 months, despite lactulose treatment.

5. Classification

8. Pathogenesis
• Ammonia Theory
• SIRS
• Manganese Theory
• Genetics
• Oxidative stress
• Neurosteroids

9. Ammonia & Brain

13. SIRS

14. Systemic inflammatory response syndrome
(SIRS) and Sepsis effect:
• 1)Hyperammonemia induction by amino acid
solution
• deterioration of the psychometric test results.
• 2)After SIRS treatment;
• hyperammonemia induction by amino acid
solution
• No effect on the psychometric test results.

16. Neurosteroids Theory

17. Manganese Theory

18. Genetics

19. Oxidative Stress

20. Clinical Examination

22. Minimal Hepatic Encephalopathy

23. Prevalence -MHE

24. Natural History of CHE

37. Serum Ammonia Levels

38. Lumbar Puncture

40. Apple store Apps
• Stoop Test
• Inhibitory Control Test
• Trail Marking Test
• Line Drawing Test

42. Management

51. Precipitating Factors Treatment

52. Enema

53. Nutrition

54. Branched Chain Aminoacids

55. Non absorbable Disacchirides

57. Antibiotics

58. Rifaximin

59. Ammonia Lowering Agents
• LOLA
• Sodium Benzoate
• Sodium Phenylbutyryte
• Glycerol phenylbuyryte
• LOPA

60. LOLA

61. LOPA
• Is similar to LOLA
• OP (OCR-002) combines ornithine and
PAA.
• It supplies urea cycle with ornithine.
• Phenylacetate + glutamine
phenylacetylglutamine [easily excreted]

62. PEG

65. Combination Therapy

66. Embolisation

67. Post TIPS
• Lactulose and Rifaximin are of no benefit
in preventing post-TIPS HE.
• The only effective therapy is to decrease
the diameter of the stent.

68. Prophylaxis
• There is no primary prophylaxis ???.
• No drug was shown to prevent 1st HE
episode after TIPS [Riggio et al., 2005].
• ??? Prevention of CHE to OHE.

69. Secondary Prophylaxis
It is the prevention of second HE episode after index
episode.
• Lactulose can be used.
• 46% recurrence of OHE due to lactulose misuse.
• Combined lactulose and rifaximin have a
decreasing risk of both breakthrough HE episodes
as well as hospitalizations when compared with
lactulose alone.
• Probiotics [VSL#3] in a recent study is equal to
lactulose [Agrawal et al., 2012].

70. When to stop secondary prophylaxis:
• Usually it is used indefinitely.
• Exception:
• Controlled precipitating factor as variceal
bleeding HE.
• Improving liver condition as treated AIH,
antiviral for HCV, HBV etc.

72. Artificial Liver Support
Not studied well
• In a small trial of 56 patients:
• MARS with albumin infusion did not show
faster recovery from HE.
• Only a mortality benefit in albumin
treated group.
• May be used for refractory cases
without survival benefit.

73. Liver Transplantation
Liver transplantation resolves both hepatic dysfunction
and portal hypertension
• It usually results in complete resolution of HE.
• Indication: recurrent or treatment resistant cases.
• MELD obstacle:
• HE does not necessarily correlate with MELD score.
• Patients with HE may be disadvantaged in the era of
MELD-based organ allocation despite a serious
impact of HE on productivity, health, and survival.

74. Flumazenil
• This drug is not frequently used.
• It transiently improves mental status in OHE without
improvement on recovery or survival.
• The effect may be of importance in marginal
situations to avoid assisted ventilation.
• Likewise, the effect may be helpful in difficult
differential diagnostic situations by confirming
reversibility (e.g., when standard therapy
unexpectedly fails or when benzodiazepine toxicity is
suspected).

75. Treatment Of CHE

77. Thank youThank you