Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution
Abstract
:1. Hepatic Encephalopathy
- Type A: hepatic encephalopathy due to of acute liver failure
- Type B: hepatic encephalopathy due to portal-systemic bypass with no intrinsic hepatocellular disease
- Type C: hepatic encephalopathy due to cirrhosis with portal hypertension or systemic shunting [2]. Type C HE is the most common form, and this review is focused on it. It is not easy to establish the incidence of HE in patients with liver disease due to the use of different clinical tools to diagnose HE and the fact that there are a lot of studies in which covert and overt HE are not well distinguished [4,5]. The prevalence of covert HE ranges between 20% and 80% among cirrhotic patients [4,6]. The prevalence of overt HE at the time of the first diagnosis of cirrhosis is between 10% and 20% [4]. In decompensated cirrhosis, the prevalence of overt HE ranges between 16% and 21% [1]. The overall incidence of overt HE after Transjugular Intrahepatic Portosystemic Shunt (TIPS) ranges between 25% and 45%, but if only new onset or worsening HE are considered, a lower percentage of HE was found [7]. HE is the complication of advanced liver disease that most frequently leads to hospitalization [8].
2. “Classical” Precipitants and Their Management
2.1. Infections
2.2. Gastrointestinal Bleeding
2.3. Dehydratation
2.4. Electrolytes Alterations
2.5. Constipation
2.6. Others
3. New Precipitants and Their Management
3.1. Muscle Alterations
3.2. Spontaneous Portosystemic Shunts (SPSS)
3.3. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
4. Overview of Available Pharmacological Treatments for HE
5. Conclusions
Funding
Informed Consent Statement
Conflicts of Interest
References
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Precipitants | Diagnosis | Management |
---|---|---|
Infections |
| Start empirical antibiotic therapy promptly is infection is suspected, (the choice of antibiotics should be guided by the environment, local antibiotic resistances and the severity and type of infection). Once the antibiogram is available, start specific antibiotic therapy. |
Gastrointestinal Bleeding | Any evidence of upper GI tract bleeding (hematemesis, melena) | Variceal Bleeding: stabilize the patient if unstable, start vasoactive drugs and antibiotic prophylaxis and perform upper endoscopy within 12 h:
|
Dehydration | Any sign of dehydration (skin and mucosal dryness, confused state) in a suitable context (patient with vomiting, diarrhea, diuretics abuse), as well as sodium, creatinine and hematocrit increase | Correct dehydration (fluid therapy, stop diuretics) |
Electrolyte Disorders | Hyponatremia (sodium < 130 mEq/L); |
|
Hypokaliemia (potassium < 3 mEq/L) | Administeroral or iv KCl | |
Constipation | More than 24 h without passing stool or demonstration of significant fecal retention in colon | Oral laxatives and/or cathartics, bowel enemas |
Malnutrition |
| Dietary advice for a correct supply of nutrients |
| Physical exercise to improve muscle trophism based on the patient’s potential | |
Portosystemic shunts | ||
| Evidence of SPSS at radiologic imaging (eco, CT scan or MRI) | Radiological shunt obliteration (BRTO, CARTO, PARTO) in case of recurrent/persistent HE |
| Anamnesis and/or evidence of TIPS at radiologic imaging | TIPS revision if necessary |
Alcohol and Drugs | Anamnesis | Stop alcohol consumption and hepatotoxic drugs |
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Bellafante, D.; Gioia, S.; Faccioli, J.; Riggio, O.; Ridola, L.; Nardelli, S. Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution. J. Clin. Med. 2023, 12, 1187. https://doi.org/10.3390/jcm12031187
Bellafante D, Gioia S, Faccioli J, Riggio O, Ridola L, Nardelli S. Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution. Journal of Clinical Medicine. 2023; 12(3):1187. https://doi.org/10.3390/jcm12031187
Chicago/Turabian StyleBellafante, Daniele, Stefania Gioia, Jessica Faccioli, Oliviero Riggio, Lorenzo Ridola, and Silvia Nardelli. 2023. "Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution" Journal of Clinical Medicine 12, no. 3: 1187. https://doi.org/10.3390/jcm12031187