Lactulose 30 mls BD to enable 2-3 soft bowel movements per day |
A non-absorbable disaccharide that is metabolized in the colon, leading to acidification of the gut and trapping of ammonia in the form of ammonium, which is then excreted in the stool. |
Lactulose is the first-line treatment for HE. It is typically administered orally or rectally in cases of coma. The goal is to achieve 2-3 soft stools per day. Overdose can lead to diarrhea and dehydration. |
Rifaximin 400 mg BD/TDS mg |
A non-systemic antibiotic that reduces the production of ammonia by gut bacteria. |
Rifaximin is often used in combination with lactulose, especially in patients who do not respond adequately to lactulose alone. It is well-tolerated and has minimal systemic side effects. |
Neomycin up to 4 g /day in divided doses |
Antibiotics are used to reduce ammonia-producing bacteria in the gut. |
Less commonly used due to the risk of nephrotoxicity (neomycin) and neurotoxicity (metronidazole). They are generally reserved for patients who cannot tolerate other treatments. |
Protein Restriction |
Dietary modification to limit the intake of dietary protein, which can reduce ammonia production. |
Once a standard practice, severe protein restriction is no longer recommended due to the risk of malnutrition. Instead, moderate protein restriction with emphasis on vegetable or dairy proteins is suggested, and branched-chain amino acids may be used. |
Manage Precipitating Factors |
Look for UGIB, SBP, infections, electrolyte imbalances, dehydration, constipation, or the use of sedatives and diuretics, which can precipitate or worsen HE. |
Identifying and managing these factors. |
Liver Transplantation |
The definitive treatment for HE in patients with end-stage liver disease. |
Liver transplantation is considered in patients with recurrent or refractory HE and decompensated cirrhosis. It offers the best long-term outcome but is limited by donor availability and patient eligibility. |