Guidelines Express | 2022 European Society of Hepatologists Clinical Practice Guidelines: Management of Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a metabolic disorder-based neuropsychiatric abnormal syndrome caused by acute and chronic severe liver dysfunction or portal veo-systemic circulation, and the main clinical manifestations are cognitive impairment, behavioral abnormalities, consciousness disorders, etc.

This recommendation is evaluated, scored, reviewed and recommended

Recommendation 1: HE typing includes type A (occurs in the context of acute liver failure), type B (caused by portosystemic shunting), and type C (occurs on the basis of cirrhosis

Recommendation 2: When there is at least a time disorientation (i.

Recommendation 3: According to international guidelines for delirium, the term "brain failure" should be replaced by "acute encephalopathy"

Recommendation 4: Patients with HE should not be classified according to the etiology of their underlying liver disease (LoE 4, I.

Recommendation 5: For patients with suspected HE, other causes of neuropsychiatric impairment should be identified in order to improve the accuracy of prognostic judgment and the therapeutic effect (LoE 4, I.

Recommendation 6: Features of occult HE and non-hepatic dysfunction causing mild cognitive impairment show a significant overlap (LoE 2).

Recommendation 7: Blood ammonia testing should be performed in patients with delirium/encephalopathy and liver disease, as normal ammonia levels can lead to questioning of the diagnosis of HE (LoE 4, I.

Recommendation 8: In patients with delirium/encephalopathy and liver disease, CT scan or MRI brain imaging (LoE 5, I.

Recommendation 9: HE does not have typical imaging features, and combined with cranial imaging findings is helpful in the diagnosis of HE (LoE 4

Recommendation 10: In patients with cirrhosis without a history of dominant HE, screening for occult HE should be performed through empirical/instrumental testing and local norms

Recommendation 11: Patients with occult HE should undergo treatment of non-absorbable disaccharides (LoE 3, I.

Recommendation 12: For patients with liver failure and dominant HE, albumin dialysis improves HE and may be considered

Recommendation 13: For patients with HE, all measures should be taken to control the progression of underlying liver disease (LoE 4, I.

Recommendation 14: For patients with HE, precipitating factors (LoE 2, I.

Recommendation 15: Patients with grade III to IV.
dominant HE are at risk of aspiration and should be treated
in an intensive care unit (ICU).
There is no single indicator that identifies which patients will benefit from ICU hospitalization, and referral relies on clinical judgment (LoE 4, I.

).

Recommendation 16: Patients with recurrent or persistent HE should be considered for liver transplantation, and the first appearance of dominant HE should be promptly referred to a transplant center for evaluation (LoE 5, I.

).

Recommendation 17: Lactulose is recommended as a secondary prevention after the first episode of dominant HE, and the dosage should reach 2 to 3 bowel movements per day (LoE 1, I.

).

Recommendation 18: Rifaximin, as an adjunct to lactulose, is recommended as a secondary prevention of ≥ 1 overt HE within 6 months after the first episode of HE (LoE 2, I.
).

Recommendation 19: For patients with gastrointestinal bleeding, rapid removal of blood from the gastrointestinal tract (lactulose or mannitol through the nasogastric tube, or lactulose enema) may prevent HE (LoE 1, I.
).

Recommendation 20: For patients with cirrhosis and those with previous overt HE episodes, rifaximin may be considered for the prevention of HE prior to non-urgent transjugular intrahepatic portal shunting (TIPS
).
Non-absorbable disaccharides are used alone or in combination and deserve further research (LoE2, I.

).

Recommendation 21: For patients with a history of dominant HE, improved liver function and nutritional status, and controlled predisposing factors, discontinuation of anti-HE therapy (LoE 5, II.
) may be considered on an individual basis
.

Recommendation 22: For patients with HE, routine zinc supplementation (LoE 2, I.
) is not recommended
.

Recommendation 23: In patients with HE, supplementation should be given in patients with confirmed or suspected vitamin/micronutrient deficiencies, as vitamin/micronutrient deficiencies may lead to metabolic encephalopathy with HE, but to be differentiated from
HE.
(LoE 4，Ⅱ)
。

Recommendation 24: For stable patients with a model of end-stage liver disease (MELD) score <11, blockage of portal shunting (LoE 4, II.
) may be considered in patients with cirrhosis with recurrent or persistent HE (despite adequate medical treatment<b10>).

Recommendation 25: For patients with relapsed/persistent HE, animal protein may be considered instead of vegetable and dairy proteins, provided that total protein intake is not affected and patient tolerance is considered (LoE 4, II.
).

Recommendation 26: For patients with end-stage liver disease and recurrent or persistent HE who do not respond to other treatments, liver transplantation evaluation should be performed (LoE 4, I.

).

Recommendation 27: For patients with hepatic myelopathy, liver transplantation should be considered as soon as possible as there are no other treatment options (LoE 4, I.

).

Recommendation 28: For patients with cirrhosis-associated Parkinson's disease, the therapeutic effect of dopaminergic is measured (LoE 2, I.
).

Recommendation 29: For patients with relapsed/persistent HE, fecal flora transplantation is not routinely recommended as a treatment option, but its clinical results validated in large randomized-placebo-controlled trials are guaranteed (LoE 2, II.

).

Recommendation 30: For patients with occult HE, anti-HE therapy should be considered to differentiate the diagnosis and prevention of dominant HE (LoE 5, I.
).

Recommendation 31: For patients with explicit HE, information on driving risks should be provided and the relevant agency should conduct an assessment of driving risks (LoE 5, I.

).

Recommendation 32: Patients planning to have non-emergency TIPS should have a comprehensive evaluation
of the present symptoms and/or history of overt and recessive HE.
A single HE episode is not absolutely contraindicated, especially due to bleeding (LoE 5, I.

).

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