Review article: the modern management of hepatic encephalopathy.
BACKGROUND; Hepatic encephalopathy, both overt and minimal, forms a continuum of cognitive change in cirrhosis. Strategies to diagnose and treat hepatic encephalopathy have evolved considerably.


OBJECTIVE
To examine the updated diagnostic and treatment strategies for hepatic encephalopathy.


METHODS
Techniques for the clinical, psychometric and neurophysiological evaluation of hepatic encephalopathy are reviewed. The methods reviewed include pure clinical scales (West-Haven), psychometric tests (PSE-syndrome test), neurophysiological tests (EEG, Critical flicker frequency, CFF) and computerized tests (Inhibitory control test, ICT).


RESULTS
Clinical scales are limited, whereas psychometric tests (specifically PSE-syndrome test), CFF and ICT can be used to diagnose minimal hepatic encephalopathy. However, there is no single test that can capture the entire spectrum of cognitive impairment. Treatment options and goals depend on the acuity of hepatic encephalopathy. In-patient management should concentrate on supportive care, precipitating factor reversal and lactulose and/or rifaximin therapy. Out-patient therapy should aim to prevent recurrences, and both lactulose and rifaximin have evidence to support their use.


CONCLUSIONS
Diagnostic techniques for hepatic encephalopathy range from simple scales to sophisticated tools. Treatment options depend on the stage of hepatic encephalopathy. The future challenge is to evaluate cognitive function as a continuum with clinically relevant outcomes and to develop well-tolerated and inexpensive treatments for hepatic encephalopathy.
Bajaj
J S
JS
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA 23249, USA. jsbajaj@vcu.edu
D000465:Algorithms; D000553:Ambulatory Care; D003072:Cognition Disorders / Q000175:diagnosis*; D003937:Diagnosis, Differential; D018450:Disease Progression; D004569:Electroencephalography; D018913:Event-Related Potentials, P300; D005425:Flicker Fusion; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000175:diagnosis* / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D006801:Humans; D007792:Lactulose / Q000627:therapeutic use*; D008103:Liver Cirrhosis / Q000150:complications* / Q000523:psychology; D016031:Liver Transplantation; D009483:Neuropsychological Tests; D011594:Psychometrics; D012294:Rifamycins / Q000627:therapeutic use; D000078262:Rifaximin; D012307:Risk Factors; D012720:Severity of Illness Index; D014481:United States
D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin