Treatment options for hepatic encephalopathy: A review

Hepatic encephalopathy (HE) encompasses a broad spectrum of neuropsychiatric manifestations that affect individuals with cirrhosis and end-stage liver disease. Although the pathogenesis of HE remains unclear, experimental and clinical data support a central role for ammonia as a key pathogenetic factor. Initial evaluation of the patient who has overt HE should include careful identification and resolution of predisposing factors and other etiologies of neurologic abnormalities. The rationale for treatment of HE is predicated on current knowledge of pathogenesis and empirical clinical experience. Despite limited evidence of efficacy from clinical studies, the nonabsorbable disaccharidcs, particularly lactulose, have been the mainstay of treatment. Alternative treatments, which are usually employed as second-line options in patients who do not respond to lactulose, include nonabsorbable antibiotics (neomycin), L-ornithine-L-aspartate, sodium benzoate, and problotics. Modification of dietary protein and supplementation with thiamine and zinc have also been reported to have beneficial effects. This review discusses the rationale, advantages, and limitations of conventional treatment options that are commonly employed in the management of HE.