Reducing the Risk of Overt Hepatic Encephalopathy Recurrence (IMAGE)
Caption
A proposed algorithm for reducing the risk of OHE and treating HE recurrence is provided and based on hepatology society guidelines and a review of the literature. In all situations, correction of known precipitating factors and/or secondary causes and avoidance of sedatives and narcotics are imperative. Lactulose is considered first-line therapy after an initial episode of HE. Lifestyle interventions, including nutritional supplementation and counseling, sleep hygiene, and mindfulness-based stress reduction therapy, may also be beneficial. Rifaximin plus lactulose therapy is recommended when additional HE episode(s) occur. Patients with recurrent or persistent HE should be evaluated for a shunt; SPSS embolization should be considered for those with an SPSS and MELD score < 11. In situations of recurrent or persistent HE refractory to pharmacologic therapy following TIPS implantation, evaluation for shunt reduction may be appropriate. Liver transplantation should be considered for patients with recurrent or persistent HE despite adequate treatment. Albumin dialysis for bridging to liver transplantation may be considered in patients with persistent, grade 3–4 HE. In addition, patient and caregiver education on HE symptoms and treatments, including the importance of long-term adherence, is advised for receptive individuals. Overall, the burden of HE is substantial and includes patient and caregiver QOL impairment and increased risk of patient hospitalization and mortality. Reducing the risk of HE recurrence is imperative given associated morbidity and mortality risks.
Credit
Nikolaos T. Pyrsopoulos
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License
CC BY-NC