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gi.hepatic-encephalopathy.core.v1PRODUCTION
gi.hepatic-encephalopathy.core.v1

Hepatic Encephalopathy (acute episode + chronic maintenance)

gastroenterologyacutechronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm hepatic encephalopathy scope; classify as overt (West Haven ≥2) vs covert (minimal/grade 1 — prevalence ~20-80% of cirrhotics by detection method, independently predicts overt HE and impaired driving/QoL); episodic vs recurrent vs persistent (AASLD/EASL 2014 PMID 25042402; ISHEN 2011)

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Advance rule
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HE type classified (overt/covert, episodic/recurrent/persistent)

Patient inputs (20)

Frailty, transplant eligibility, differential diagnosis

Hypotension suggests GI bleed or sepsis as precipitant (AASLD/EASL 2014)

Tachycardia screens for infection/bleed precipitant (AASLD/EASL 2014)

Fever screens for infection precipitant — most common trigger (AASLD/EASL 2014)

West Haven grade 0-IV classification drives treatment intensity (AASLD/EASL 2014; ISHEN 2011)

Infection, GI bleed, constipation, medications (opioids/benzos/sedatives), dehydration, electrolyte imbalance, TIPS, dietary protein excess (rare) (AASLD/EASL 2014)

Nonadherence to lactulose is most common cause of recurrent HE (AASLD/EASL 2014)

Recurrent (≥2 bouts in 6 months) vs episodic — drives secondary prophylaxis decision (Bass NEJM 2010)

Opioids, benzodiazepines, sedatives, diuretics as precipitants; verify lactulose/rifaximin compliance (AASLD/EASL 2014)

AKI/HRS as precipitant; MELD-Na component (AASLD/EASL 2014)

Hyponatremia as precipitant; MELD-Na component (AASLD/EASL 2014)

Hypokalemia from diuretics precipitates HE via renal ammoniagenesis (AASLD/EASL 2014)

Hypoglycemia as precipitant in advanced liver disease

WBC for infection screen; Hgb for GI bleed precipitant (AASLD/EASL 2014)

MELD-Na severity; worsening jaundice = decompensation (AASLD/EASL 2014)

MELD-Na component; coagulopathy severity (AASLD/EASL 2014)

Hypoxia in grade 3-4 HE — airway protection assessment

UTI as infection precipitant screen (AASLD/EASL 2014)

Pneumonia as infection precipitant screen (AASLD/EASL 2014)

Supportive but NOT required for HE diagnosis; normal ammonia does not exclude HE (AASLD/EASL 2014)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateninghe_grade_3_4
    West Haven grade 3 (somnolence/stupor but rousable) or grade 4 (coma, unresponsive) — airway at risk (AASLD/EASL 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghe_with_gi_bleed
    HE episode precipitated by GI bleed — hematemesis, melena, or significant Hgb drop in cirrhotic (AASLD/EASL 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehe_with_infection
    HE precipitated by infection — SBP, UTI, pneumonia, cellulitis, or bacteremia in cirrhotic (AASLD/EASL 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehe_no_improvement_48h
    No clinical improvement in West Haven grade at 48h despite lactulose and precipitant treatment (AASLD/EASL 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Acute HE episode — lactulose + rifaximin + precipitant treatment (AASLD/EASL 2014)
axis: he_acute_episode_axisstep 1 - Step 1 — Lactulose titration (first-line for all overt HE)
Selected step "Step 1 — Lactulose titration (first-line for all overt HE)" — Any overt HE episode (West Haven grade ≥2)
  • lactulose
    first line
    osmotic_laxative_HE
    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)
    triggers: overt_HE_grade_2_3_4
    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)
    rxcui 6218
  • lactulose_enema
    first line
    osmotic_laxative_HE
    300 mL in 700 mL water PR retention enema × 30-60 min, q4-6h • PR • q4-6h
    triggers: grade_3_4_HE_unable_to_take_PO, ileus
    AASLD/EASL 2014 — rectal lactulose for patients unable to take PO (grade 3-4 or ileus)
    rxcui 6218

outpatient playbook — drug actions (2)

  1. 1. lactulose secondary prophylaxis
    25 mL PO BID-TID titrated to 2-3 BMs/day • PO • BID-TID
    trigger: Any prior overt HE episode
    AASLD/EASL 2014 — indefinite secondary prophylaxis
  2. 2. rifaximin secondary prophylaxis
    550 mg PO BID • PO • BID
    trigger: Recurrent HE (≥2 episodes) or post-first episode
    Bass NEJM 2010 — add to lactulose for secondary prophylaxis indefinitely

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Confusion, asterixis, or personality change in cirrhotic; Sleep-wake reversal or day-night inversion; Progressive somnolence or coma in liver disease.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hepatic Encephalopathy (acute episode + chronic maintenance)** (gi.hepatic-encephalopathy.core.v1).
Phenotype framing: Exclude non-HE causes of AMS in cirrhotic: Wernicke, hypoglycemia, SDH/ICH, hyponatremia, medication toxicity, septic encephalopathy, post-ictal, uremia (AASLD/EASL 2014)
Scope: Confirm hepatic encephalopathy scope; classify as overt (West Haven ≥2) vs covert (minimal/grade 1 — prevalence ~20-80% of cirrhotics by detection method, independently predicts overt HE and impaired driving/QoL); episodic vs recurrent vs persistent (AASLD/EASL 2014 PMID 25042402; ISHEN 2011)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute HE episode — lactulose + rifaximin + precipitant treatment (AASLD/EASL 2014)** — step "Step 1 — Lactulose titration (first-line for all overt HE)".
1. 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) (osmotic_laxative_HE, first line) — 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)
2. lactulose_enema 300 mL in 700 mL water PR retention enema × 30-60 min, q4-6h PR q4-6h (osmotic_laxative_HE, first line) — AASLD/EASL 2014 — rectal lactulose for patients unable to take PO (grade 3-4 or ileus)

Setting playbook (outpatient) — Secondary prophylaxis with lactulose ± rifaximin; precipitant prevention; nutrition optimization; driving fitness; transplant evaluation; caregiver education
3. lactulose secondary prophylaxis 25 mL PO BID-TID titrated to 2-3 BMs/day PO BID-TID — Any prior overt HE episode (AASLD/EASL 2014 — indefinite secondary prophylaxis)
4. rifaximin secondary prophylaxis 550 mg PO BID PO BID — Recurrent HE (≥2 episodes) or post-first episode (Bass NEJM 2010 — add to lactulose for secondary prophylaxis indefinitely)

Non-pharmacologic actions:
- Protein 1.2-1.5 g/kg/day — protein restriction is harmful and NOT recommended (ISHEN 2014 consensus)
- Late evening snack (ISHEN 2014; EASL 2018)
- Avoid opioids, benzodiazepines, sedatives (AASLD/EASL 2014)
- Driving assessment — overt HE patients should not drive; covert HE patients need formal psychometric evaluation (AASLD/EASL 2014)
- Caregiver education on early HE signs (confusion, sleep changes, asterixis) and when to present to ED (AASLD/EASL 2014)
- Alcohol cessation if applicable (AASLD/EASL 2014)
- Vaccinations (HAV, HBV, flu, PCV20, COVID) (AASLD 2023)

AVOID / contraindication checks:
- Opioid avoid or minimize — HE precipitant; reduces GI motility, worsens constipation (AASLD/EASL 2014)
- Benzodiazepine avoid — HE precipitant; GABA ergic potentiation in HE (AASLD/EASL 2014)
- Sedative_hypnotic avoid — all sedatives worsen HE (AASLD/EASL 2014)
- Lactulose excessive dosing avoid — diarrhea → dehydration → hyponatremia → worsened HE (AASLD/EASL 2014)
- NSAID avoid in cirrhosis — renal and GI bleed risk (AASLD/EASL 2014)
- Aminoglycoside avoid — nephrotoxicity in cirrhosis (AASLD/EASL 2014)
- Protein_restriction NOT recommended — deleterious; causes sarcopenia and worsens HE long term (ISHEN 2014 consensus; EASL 2018)

Monitoring

Regimen monitoring:
- West Haven grade q4-8h inpatient; at each outpatient visit (AASLD/EASL 2014)
- Lactulose titration to 2-3 soft BMs/day — NOT more (AASLD/EASL 2014)
- BMP daily inpatient for Na/K/Cr/glucose (AASLD/EASL 2014)
- Ammonia level NOT recommended for routine monitoring — does not correlate with HE grade and should not guide treatment (AASLD/EASL 2014)
- Stool output log — target 2-3 BMs/day (AASLD/EASL 2014)
- Daily weight for dehydration from lactulose excess (AASLD/EASL 2014)
- Rifaximin — no routine drug level monitoring needed; minimal systemic absorption (Bass NEJM 2010)

Setting (outpatient) monitoring:
- Hepatology q1-3mo (AASLD/EASL 2014)
- Lactulose adherence and BM diary at each visit (AASLD/EASL 2014)
- MELD-Na q3-6mo (AASLD/EASL 2014)
- LFT + BMP q3-6mo (AASLD/EASL 2014)
- Psychometric testing for covert HE if driving or work fitness concern (AASLD/EASL 2014)

Follow-up plan: 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)
- Close-out criterion: follow-up and prophylaxis plan set

Monitoring phase: West Haven grade q4-8h inpatient; lactulose titration to 2-3 BMs/day; ammonia trend (NOT as sole guide); daily BMP for electrolytes; monitor for over-sedation from lactulose excess (AASLD/EASL 2014)

Disposition

Current setting: outpatient — Secondary prophylaxis with lactulose ± rifaximin; precipitant prevention; nutrition optimization; driving fitness; transplant evaluation; caregiver education

Disposition criteria:
- Continue outpatient management if HE controlled on prophylaxis, compliant with lactulose, no new precipitants (AASLD/EASL 2014)
- Transplant referral if MELD ≥15 or recurrent HE despite prophylaxis (AASLD/EASL 2014)

Escalation triggers (move to higher acuity):
- New overt HE episode (grade ≥2) → ED evaluation + admission (AASLD/EASL 2014)
- Increasing confusion or new asterixis → same-day evaluation (AASLD/EASL 2014)
- Fever, abdominal pain, GI bleed → ED for precipitant workup (AASLD/EASL 2014)

Patient Action Plan

**Hepatic encephalopathy action plan**
Personalised values: baseline_west_haven_grade, home_meds_lactulose_rifaximin, transplant_status, baseline_MELD_Na.

**Stable — continue prophylaxis** (green):
Triggers:
- 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
Actions:
- 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

**Caution — early HE signs, contact hepatology within 24h** (yellow):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- Mild confusion or personality changes
- Fewer BMs than usual despite lactulose
- New sleep pattern changes

**Medical alert — go to ED now** (red):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- Any red zone symptom — ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)
- [SEVERE] HE precipitated by infection — SBP, UTI, pneumonia, cellulitis, or bacteremia in cirrhotic (AASLD/EASL 2014)

Citations

- AASLD/EASL 2014 Practice Guideline on Hepatic Encephalopathy in Chronic Liver Disease + Bass NEJM 2010 (rifaximin) + ISHEN 2014 (nutrition consensus) [PMID:25042402](https://pubmed.ncbi.nlm.nih.gov/25042402/)
- Cited evidence (PMID 20335583) [PMID:20335583](https://pubmed.ncbi.nlm.nih.gov/20335583/)
- Cited evidence (PMID 24365449) [PMID:24365449](https://pubmed.ncbi.nlm.nih.gov/24365449/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD/EASL 2014 Practice Guideline on Hepatic Encephalopathy in Chronic Liver Disease + Bass NEJM 2010 (rifaximin) + ISHEN 2014 (nutrition consensus) — PMID:25042402
  • Cited evidence (PMID 20335583) — PMID:20335583
  • Cited evidence (PMID 24365449) — PMID:24365449