Hepatic encephalopathy: current management strategies and treatment, including management and monitoring of cerebral edema and intracranial hypertension in fulminant hepatic failure

Abstract

Purpose of review: Hepatic encephalopathy is a syndrome whose pathophysiology is poorly understood, for which we lack high-quality diagnostic tests and markers, and whose treatment has improved only slightly over the last several decades. Serum ammonia levels remain the diagnostic gold standard.

Recent findings: Hepatic encephalopathy can be precipitated by several of the complications of cirrhosis; effective treatment of precipitants is as important as treatment of the encephalopathy itself. Therapy with lactulose and enteral antibiotics is appropriate in any hospitalized patient with more than trivial hepatic encephalopathy. Rifaximin is increasingly important as a therapy for hospitalized patients with hepatic encephalopathy. High-grade encephalopathy continues to carry a high mortality.

Summary: Current diagnostic tests are imperfect, and modern therapy is nonspecific. No cost-efficient or more effective alternatives to either are likely to enter into clinical practice in the short-term future.