An episode of overt hepatic encephalopathy in a patient with underlying liver disease. First-line management focuses on rapidly establishing why the episode occurred and correcting those causes before any additional intervention is considered.
The primary step is a systematic search for, and correction of, recognised precipitating events. This approach precedes specific anti-HE treatment and addresses the underlying liver disease concurrently.
The primary intervention in patients with overt HE is a search for, and correction of, any precipitating factors.
This exercise always precedes specific anti-HE treatment and up to 90% of the patients can be expected to recover from episodic overt HE by correction of one or more precipitating factors.
Finally, rapid removal of blood from the gastrointestinal tract and rapid resolution of constipation have been shown to improve recovery from an episode of overt HE.
In patients with HE, all measures to control progression of the underlying liver disease should be undertaken (LoE 4, strong recommendation, 100% consensus).
Recognised precipitating events are constipation, gastrointestinal bleeding, infections, hyponatremia, and dehydration/diuretic overdose.
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