ACG Clinical Guideline: Preventive Care for Patients With Cirrhosis.

In adults with cirrhosis, hepatic encephalopathy (HE) is a clinical diagnosis. It is graded by West Haven (minimal plus grade 1 = covert; grades 2-4 = overt) and made only after other causes of altered mentation are excluded. Routine brain imaging is not needed in a patient with cirrhosis and confusion. Do not routinely check serum ammonia to guide HE treatment (conditional, very low certainty), and do not use ammonia alone to diagnose minimal or covert HE (conditional, very low). Ammonia should not be used to grade overt HE or to titrate therapy, though EASL 2022 notes that a normal level calls the diagnosis into question. For covert or minimal HE, use a single psychometric or neurophysiological test rather than two in combination (conditional, very low). Lactulose is suggested over no treatment for covert or minimal HE (conditional, low), but the evidence is insufficient to recommend routine treatment to prevent overt HE. In every episode of overt HE, search for and treat precipitants: infection, GI bleeding, dehydration or diuretic excess, electrolyte disturbance, constipation, sedatives. Reassess if the patient has not improved within 48-72 h. Lactulose is first-line for overt HE (strong, moderate), titrated to 2-3 soft bowel movements a day, given orally or by enema in grade 3-4. High-volume polyethylene glycol (about 4 L) is suggested as an alternative to lactulose (conditional, low). In acute inpatient overt HE, adding rifaximin to lactulose is suggested over lactulose alone (conditional, low). After a first episode of overt HE, give lactulose as secondary prophylaxis titrated to 2-3 BM/day. Outpatient rifaximin is suggested to prevent recurrence (conditional, low). Adding rifaximin 550 mg twice daily to lactulose is strongly recommended for recurrence while on lactulose (strong, high). If symptoms persist on lactulose plus rifaximin, zinc may be added when blood zinc is low (conditional, very low). Do not restrict protein (conditional, very low). Target protein 1.2-1.5 g/kg/day (strong, moderate) and give a late-evening snack (conditional, very low). Use BCAA supplementation when food alone cannot meet protein needs (strong, moderate). Before elective TIPS in decompensated cirrhosis, start rifaximin 14 days ahead and continue it for at least 6 months, with or without prior overt HE (strong, moderate). Extrahepatic collaterals may be embolized at the time of TIPS to reduce post-TIPS HE (conditional, low). For HE refractory to optimized medical therapy, embolization of a spontaneous portosystemic shunt is suggested in patients with adequate hepatic function and no contraindications (conditional, very low). Post-TIPS refractory HE may warrant TIPS reduction. Refer for transplant evaluation in patients with recurrent or persistent HE. In patients with multiple HE episodes and MELD <15, evaluate candidacy for living-donor liver transplant (conditional, low). Give oral and written advice against driving.