This protocol addresses patients with liver cirrhosis who develop overt hepatic encephalopathy (OHE) presenting at West Haven grade 2–4, with clinically evident altered mental status. HE should be suspected in any patient with cirrhosis and altered mental status.
Overt HE (grades 2–4) is differentiated from covert or minimal forms by its clinical obviousness and severity of neurological impairment. The patient's West Haven grade and ability to safely take oral medication directly shape which approach is appropriate — the complete grade-specific algorithm is accessible via the protocol link below.
Management involves a targeted bowel-based intervention combined with identification and treatment of any precipitating or contributing factors. The route and intensity of the intervention depend on the patient's grade and clinical status. Full route-specific and dose-specific guidance is not shown here.
DOI: 10.14309/ajg.0000000000003899
This is to differentiate it from the clinically obvious overt HE (OHE) forms (i.e., grades 2–4).
HE should be suspected in any patient with cirrhosis and altered mental status.
In patients with OHE, we recommend treatment with lactulose to improve patient outcomes and prevent recurrence of OHE episodes (strong recommendation, moderate certainty of evidence).
Improvement in mental status with first-line treatment is expected within 24–48 hours.
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