Severe acute hepatic encephalopathy

Drug therapy for encephalopathy reduces the absorption of toxic amines by decreasing the numbers of colonic bacteria or by lowering the colonic pH.

For severe acute hepatic encephalopathy, use:

When the laxative effect has been achieved, reduce dosing frequency; use:

Lactulose increases intestinal gas production; monitor patients for bowel distension when using high doses. For unconscious patients or patients who cannot swallow, lactulose may be given by nasogastric tube or mixed with water and given rectally. Take care when administering nasogastric lactulose, and with oral and nasogastric feeding in patients with a reduced level of consciousness without airway protection, because they are at risk of aspiration.

If no precipitant of acute encephalopathy is readily identifiable, start empirical treatment for infection while waiting for results of investigations (eg cultures). Use antibiotic therapy as for spontaneous bacterial peritonitis. Modify antibiotic therapy based on the results of culture and susceptibility testing. Continue antibiotic therapy until the patient has clinically improved (usually for 3 to 5 days); stop therapy earlier if an alternative precipitant is identified, or if culture results are negative.