Treatment



Treatment of hepatic encephalopathy is based on four simple principles:
Identification and Treatment or Precipitating Fac­tors. lists several important factors that may precipitate or severely aggravate hepatic encephalopathy in patients with severe liver dis­ease. Gastrointestinal bleeding and increased pro­tein intake may provide increased substrate for the bacterial or metabolic formation of nitrogen­ous compounds that induce encephalopathy. In patients prone to develop hepatic encephalopathy there is a markedly increased sensitivity to central nervous system-depressant drugs, and their use should be avoided in these patients.

Reduction and Elimination of Substrate for the Gen­eration or Nitrogenous Compounds, (a) Dietary pro­tein restriction. Patients in coma should receive no protein, whereas those with mild encephalop­athy may benefit from restriction of protein intake to 40 to 60 grams per day. Vegetable protein diets also appear to be less encephalopathogenic. (b) Bowel cleansing. This is important mainly in pa­tients with encephalopathy precipitated by gas­trointestinal bleeding or constipation, and is achieved by administration of enemas.

Reduction of Colonic Bacteria. Neomycin admin­istered orally reduces the number of bacteria that are responsible for production of ammonia and other nitrogenous compounds.

Prevention of Ammonia Diffusion from the Bowel. This is achieved by administration of lactulose, a nonabsorbable disaccharide, which, when fer­mented to organic acids by colonic bacteria, leads to a lower stool pH. This lowered pH traps am­monia in the colon as nondiffusible NH4~ ions, but other mechanisms such as inhibition of bac­terial ammonia production may also be important.