Hepatic Encephalopathy with Acute Decompensated Cirrhosis and Acute-on- Chronic Liver Failure

Hepatic encephalopathy (HE) is one of the major complications of cirrhosis, and recent evidence suggests that hospitalized cirrhotic HE patients with acute decompensation and, especially, acute-on-chronic liver failure (ACLF) have extremely poor outcomes. The current review article discusses the pathophysiology and management of such patients. Highlights are as follows:

• Although the exact mechanism of HE in these patients is unknown, systemic inflammation (from bacterial translocation, sepsis, and insulin resistance), interorgan ammonia trafficking, and oxidative stress, all modulated by glutaminase gene alteration, likely play key roles.

• Because HE in this setting is associated with substantial morbidity and mortality, patients should be admitted to an intensive care unit, and general measures such as airway, breathing, and circulation should be considered.

• Because precipitating events occur in up to 60% of patients, identifying factors such as over-diuresis, intravascular volume depletion, bacterial infections, and gastrointestinal bleeding with subsequent correction is critical.

• Specific treatments for HE that should be considered once precipitating events are addressed include the use of lactulose as well as rifaximin, not only for HE treatment but also for its possible role in gut decontamination.

• In cases of refractory HE where large spontaneous portacaval shunting is present, selective embolization may be effective when possible and in the appropriate patients (MELD score of ≤11 in one study).