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Hepatic encephalopathy in adults: Treatment

Peter Ferenci, MD
Section Editor
Bruce A Runyon, MD
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Hepatic encephalopathy or portal-systemic encephalopathy represents a reversible impairment of neuropsychiatric function associated with impaired hepatic function. Despite the frequency of the condition, we lack a clear understanding of its pathogenesis. Nevertheless, decades of experience have suggested that an increase in ammonia concentration is implicated and that there may be a role for inhibitory neurotransmission through gamma-aminobutyric acid (GABA) receptors in the central nervous system and changes in central neurotransmitters and circulating amino acids. (See "Hepatic encephalopathy: Pathogenesis".)

Currently available therapies for hepatic encephalopathy are based on these hypotheses (table 1). Some treatments are based on clinical observations, some on extrapolation of experimental data obtained in animal models of hepatic encephalopathy, and a smaller number on randomized trials. However, there are a number of problems that interfere with the interpretation of data from these studies:

A common problem is the variety of clinical conditions that are summarized under the term "hepatic encephalopathy." The clinical features of hepatic encephalopathy include a wide range of neuropsychiatric symptoms ranging from minor, not readily discernible signs of altered brain function (minimal hepatic encephalopathy), to overt psychiatric and/or neurologic symptoms, to deep coma. As a result, the methods to quantify treatment effects and endpoints are highly variable. (See "Hepatic encephalopathy in adults: Clinical manifestations and diagnosis".)

It is not known if data regarding treatment in patients with overt hepatic encephalopathy can be extrapolated to minimal hepatic encephalopathy and vice versa. However, many studies included patients both with overt and minimal hepatic encephalopathy.

Another important variable is the treatment of control groups. Very few studies use a placebo; in most cases, the new drug was compared with "standard treatment" (which by itself may be highly effective) or specifically to lactulose.

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Literature review current through: Nov 2017. | This topic last updated: Aug 17, 2017.
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