Written by Clay Smith
Spoon Feed
What you need to know from the ACG hepatic encephalopathy (HE) guidelines: HE can be subtle; lactulose is good (as is rifaximin); ammonia is not very helpful.
All you ever wanted to know about HE
- Minimal or covert HE can be subtle (as the name implies).
- Asterixis alone is not enough to diagnose it.
- Ammonia levels don’t help.
- Hepatologists should do subtle neuropsychiatric testing for it.
- My take: If family says, “They ain’t right,” they should NOT be driving or doing cognitively critical tasks.
- And they need to start lactulose.
- For overt HE (needing hospitalization):
- Once again, ammonia levels don’t help make the diagnosis or guide treatment.
- Guidelines say no imaging. Are they crazy? Feel free to get a head CT in these altered coagulopathic patients.
- Rule out: “bleeding, infection, sedating medications, and toxic and metabolic abnormalities.”
- Start lactulose. Consider 4L polyethylene glycol (bowel prep) instead of lactulose (which seems not very nice).
- They recommend adding rifaxamin to lactulose.
- For prevention, patients should keep taking lactulose, with goal 2–3 soft BMs per day. They suggest adding rifaximin outpatient as well, and adding zinc (if they have low zinc) to both if refractory HE.
- The rest is not very relevant for emergency clinicians unless you are into sarcopenia, protein intake goals, TIPS, and transplant.
How will this change my practice?
The subtlety of minimal or covert HE impressed me. Though it may not be clinically obvious, these patients are impaired and should not be driving, doing dangerous stuff, or making big decisions. We won’t do complex neuropsychiatric tests, but if family feels they are “off,” we should warn them and ensure they have hepatology follow up. I will also ask my friendly neighborhood liver team if they want to add rifaximin. It seems helpful.
Source
ACG Clinical Guideline: Hepatic Encephalopathy. Am J Gastroenterol. 2026 Mar 1;121(3):588-618. doi: 10.14309/ajg.0000000000003899. Epub 2026 Mar 3. PMID: 41773757.
