EASL Clinical Practice Guidelines


After a hospital admission for HE, the following issues should be addressed.

Discharge from hospital

  1. The medical team should confirm the neurological status before discharge and judge to what extent the patient's neurological deficits could be attributable to HE, or to other neurological comorbidities, for appropriate discharge planning. They should inform caregivers that the neurological status may change once the acute illness has settled and that requirement for medication could change.
  2. Precipitating and risk factors for development of HE should be recognized. Future clinical management should be planned according to (1) potential for improvement of liver function (e.g., acute alcoholic hepatitis, autoimmune hepatitis, and hepatitis B), (2) presence of large portosystemic shunts (which may be suitable for occlusion), and (3) characteristics of precipitating factors (e.g., prevention of infection, avoidance of recurrent GI bleeding, diuretics, or constipation).
  3. Out-patient postdischarge consultations should be planned to adjust treatment and prevent the reappearance of precipitating factors. Close liaison should be made with the patient's family, the general practitioner, and other caregivers in the primary health service, so that all parties involved understand how to manage HE in the specific patient and prevent repeated hospitalizations.

Preventive care after discharge

  1. Education of patients and relatives should include (1) effects of medication (lactulose, rifaximin, and so on) and the potential side effects (e.g., diarrhea), (2) importance of adherence, (3) early signs of recurring HE, and (4) actions to be taken if recurrence (e.g., anticonstipation measures for mild recurrence and referral to general practitioner or hospital if HE with fever).
  2. Prevention of recurrence: the underlying liver pathology may improve with time, nutrition, or specific measures, but usually patients who have developed OHE have advanced liver failure without much hope for functional improvements and are often potential LT candidates. Managing the complications of cirrhosis (e.g., spontaneous bacterial peritonitis and GI bleeding) should be instituted according to available guidelines. Pharmacological secondary prevention is mentioned above.
  3. Monitoring neurological manifestations is necessary in patients with persisting HE to adjust treatment and in patients with previous HE to investigate the presence and degree of MHE or CHE or signs of recurring HE. The cognitive assessment depends on the available normative data and local resources. The motor assessment should include evaluation of gait and walking and consider the risk of falls.
  4. The socioeconomic implications of persisting HE or MHE or CHE may be very profound. They include a decline in work performance, impairment in quality of life, and increase in the risk of accidents. These patients often require economic support and extensive care from the public social support system and may include their relatives. All these issues should be incorporated into the follow-up plan.
  5. Treatment endpoints depend on the monitoring used and the specialist clinic, but at least they have to cover two aspects: (1) cognitive performance (improvement in one accepted test as a minimum) and (2) daily life autonomy (basic and operational abilities).
  6. Nutritional aspects: weight loss with sarcopenia may worsen HE, and, accordingly, the nutritional priority is to provide enough protein and energy to favor a positive nitrogen balance and increase in muscle mass, as recommended above.
  7. Portosystemic shunt: occlusion of a dominant shunt may improve HE in patients with recurring HE and good liver function [114]. Because the current experience is limited, the risks and benefits must be weighed before employing this strategy.