Patient handout

Hepatic Encephalopathy (acute episode + chronic maintenance)

PRODUCTION

1. Your condition

This handout is for hepatic encephalopathy (acute episode + chronic maintenance). Your care team identified this based on: confusion, asterixis, or personality change in cirrhotic.

Other reasons your team may use this plan: sleep-wake reversal or day-night inversion; progressive somnolence or coma in liver disease; elevated ammonia in known cirrhosis (note: not required for diagnosis per aasld/easl 2014).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lactulose	25 mL PO q1-2h until first bowel movement, then 25 mL PO TID titrated to 2-3 soft BMs/day	PO	TID (after initial loading)	AASLD/EASL 2014 — first-line; reduces ammonia via gut acidification + cathartic effect; titrate to 2-3 BMs/day (not more — excessive diarrhea causes dehydration and worsens HE)
lactulose_enema	300 mL in 700 mL water PR retention enema × 30-60 min, q4-6h	PR	q4-6h	AASLD/EASL 2014 — rectal lactulose for patients unable to take PO (grade 3-4 or ileus)

Plan: Acute HE episode — lactulose + rifaximin + precipitant treatment (AASLD/EASL 2014)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable — continue prophylaxis

If you have:

Clear thinking, no confusion or personality changes
Normal sleep pattern
2-3 soft bowel movements per day on lactulose
Eating well, taking all medications as prescribed
No tremor or hand-flapping

Do this:

Take lactulose as prescribed — titrate to 2-3 soft BMs/day
Take rifaximin 550 mg twice daily if prescribed
Eat adequate protein (1.2-1.5 g/kg/day) — do NOT restrict protein
Eat a late evening snack to prevent overnight muscle breakdown
Avoid alcohol, opioids, sleeping pills, and sedatives
Keep all hepatology appointments

YELLOW — Caution — early HE signs, contact hepatology within 24h

If you have:

Mild forgetfulness or trouble concentrating
Sleep-wake reversal (sleeping during day, awake at night)
Mild personality changes noticed by family
Fewer than 2 BMs/day despite lactulose
Constipation for >1 day
New mild hand tremor

Do this:

Increase lactulose dose to achieve 2-3 soft BMs/day
Avoid all sedatives, opioids, and sleeping pills
Check for constipation — take extra lactulose if needed
Contact hepatology team within 24 hours
Have a caregiver stay with you
Do NOT drive

Call your provider if:

Mild confusion or personality changes
Fewer BMs than usual despite lactulose
New sleep pattern changes

RED — Medical alert — go to ED now

If you have:

Severe confusion, disorientation, or inability to follow commands
Very sleepy, difficult to wake
Hand-flapping tremor (asterixis)
Slurred speech or stumbling
Fever or abdominal pain (infection may be causing HE)
Vomiting blood or black tarry stool
Cannot take lactulose by mouth

Do this:

Call 911 / go to nearest ED immediately
Bring updated medication list
Family/caregiver MUST accompany — patient may not be able to communicate
Notify hepatology team of ED presentation

Call your provider if:

Any red zone symptom — ED now, do not wait

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

West Haven grade 3 (somnolence/stupor but rousable) or grade 4 (coma, unresponsive) — airway at risk (AASLD/EASL 2014)(life-threatening)
HE episode precipitated by GI bleed — hematemesis, melena, or significant Hgb drop in cirrhotic (AASLD/EASL 2014)(life-threatening)
HE precipitated by infection — SBP, UTI, pneumonia, cellulitis, or bacteremia in cirrhotic (AASLD/EASL 2014)
No clinical improvement in West Haven grade at 48h despite lactulose and precipitant treatment (AASLD/EASL 2014)

5. Follow-up

Secondary prophylaxis: lactulose + rifaximin indefinitely for recurrent HE (Bass NEJM 2010); hepatology q1-3mo; transplant evaluation; driving fitness assessment; caregiver education; nutrition counselling — high protein, NOT restricted (ISHEN 2014)

6. Sources

Guideline: AASLD/EASL 2014 Practice Guideline on Hepatic Encephalopathy in Chronic Liver Disease + Bass NEJM 2010 (rifaximin) + ISHEN 2014 (nutrition consensus)