Nontraditional Treatment of Hepatic Encephalopathy

Abnormalities in ammonia production and metabolism constitute the key factors in the development of HE. Traditional treatments have targeted the hyperammonemic state. However, the etiologies of HE are multifactorial and thus present a myriad of possible treatment targets. The gut microbiome, for example, may be considered a driver in the progression of cognitive dysfunction in cirrhosis, and nontraditional treatments such as probiotics and FMT may be viable alternative therapies for HE. Other nontraditional treatments targeted at the urea cycle or protein synthesis, such as GPB or amino acids, may be considered in refractory cases but are not supported by available data. Further investigation with high-quality studies is warranted to determine the role of gut microbiome modulation and ammonia detoxification in the clinical treatment and resolution of HE. Liver support devices such as MARS offer an alternative to refractory HE cases but are not widely available and may have significant costs associated. Finally, although LT is not warranted in all cases of HE, it remains the definitive treatment for HE in cirrhosis.