Hepatic encephalopathy (HE)
HE is a complex and potentially reversible neuropsychiatric syndrome seen in patients with ELD. It may be episodic and it a result of the cirrhotic liver’s inability to break down nitrogen-based substances that arise from the bacteria in the gut and cross the blood-brain barrier (Dooley et al, 2011). Several tools are used to assess HE, including the West-Haven scale (Ortiz et al, 2007).
There may be precipitating factors in patients with cirrhosis (Box 2), which need to be identified and treated accordingly, although in 20-30% of patients no precipitating cause is found (Dooley et al, 2011). HE negatively affects quality of life and can be distressing for patients and their families. It also affects decision-making processes, so mental capacity needs to be assessed regularly.
Treatment of HE aims to cut ammonia levels in the gastrointestinal tract, using aperients such as lactulose, which assist with evacuating bowel contents. However, it can be difficult for patients to manage this, and side-effects can reduce adherence. Patients are advised to titrate the aperients dose so they aim to have at least two soft, bulky stools a day without developing diarrhoea. Rifaximin, a minimally absorbed, broad-spectrum antibiotic has been effective at treating HE and reducing hospital admissions (Felicilda-Reynaldo, 2012).