Hepatic encephalopathy (HE) is one of the most challenging complications of cirrhosis, affecting patients’ cognitive function and quality of life while driving frequent hospital readmissions. For clinicians managing these complex patients, understanding HE’s presentation, diagnosis, and evidence-based treatment approaches is essential to improving outcomes.
What is HE?
HE is a neuropsychiatric complication of liver dysfunction. When the liver cannot adequately detoxify blood, ammonia and other inflammatory compounds accumulate and cross the blood–brain barrier, leading to impaired brain function.
It is also categorized into three types based on underlying cause:
- Type A – Due to acute liver failure. This is a rapid deterioration of liver function in individuals without pre-existing liver disease.
- Type B – Related to portal–systemic bypass without intrinsic liver disease.
- Type C – The most common type, associated with chronic liver disease, especially cirrhosis.
How common is it?
HE is highly prevalent. Up to 70% of individuals with cirrhosis will experience symptoms at some point, ranging from subtle deficits to overt neuropsychiatric changes.
Symptoms
One of the biggest challenges with HE is how subtly it can begin. Patients often don’t notice early changes; instead, a family member or caregiver may be the first to pick up on cognitive or behavioural shifts.
Milder or early findings include:
- Memory loss, forgetfulness
- Reduced concentration
- Slowed reaction time
- Insomnia or disrupted sleep–wake patterns
- Worsening handwriting or impaired fine motor skills
- Increased anxiety or irritability
More advanced symptoms can look like:
- Asterixis
- Gross disorientation
- Noticeable personality or behavioural changes
- Slurred speech
- Slowed or sluggish movement
- Somnolence, confusion, or stupor
Treatment Approaches
Management of HE centres on two primary therapeutic strategies:
Lactulose remains the cornerstone of treatment, working to reduce ammonia absorption from the gut.
Rifaximin, a minimally absorbed antibiotic, reduces ammonia-producing bacteria in the gut. When used in combination with lactulose, it has demonstrated superior efficacy in reducing HE recurrence compared to lactulose alone.
Advance your HE management skills
To help clinicians navigate these challenges, we’re offering a comprehensive 60-minute webinar: Optimizing Hepatic Encephalopathy Care Across Settings: Standardized Tools for Hospital and Home.
This MOC Section 1–accredited program provides:
- Practical strategies for timely HE diagnosis in hospitalized patients
- Evidence-based treatment protocols using lactulose and rifaximin
- Standardized discharge planning tools and order sets
- Real-world scenarios demonstrating best practices
- Approaches to reduce recurrences and improve care transitions
Through clinical case discussions and actionable protocols, you’ll gain the tools needed to streamline HE care and improve patient outcomes across all settings.
Register today to strengthen your approach to this challenging condition and earn MOC credit.
This program has received financial support from Lupin Pharma Canada in the form of an unrestricted educational grant.