Hepatic encephalopathy (HE), a reversible syndrome of impaired brain function, is one of the complications of portal hypertension and decompensated liver disease. 

Despite the clear role of ammonia in the pathogenesis of HE, the pathogenesis of HE is multifactorial, with numerous mechanisms causing functional impairment of neuronal cells. The initial management of HE includes supportive care and stabilization by providing appropriate nutritional support. After that, the focus shifts to identifying and treating the precipitating factors. Many therapeutic agents are available for managing HE, most of which help to lower the gut nitrogen load and, ultimately, the serum ammonia level. 

HE treatment involves using gut flora modifying agents like Nonabsorbable disaccharides, Antibiotics (rifaximin, neomycin, vancomycin, and metronidazole), Probiotics, or Fecal microbiota transplant. Among the nonabsorbable disaccharides, lactulose and lactitol are the first-line therapeutic agents for treating HE and have shown significant improvement in cognition and quality of life in patients with MHE, with lactitol having fewer side effects compared to lactulose.

Nutrition, dietary modification, and supplementation are also crucial parts of HE management, with zinc, Branched-chain amino acids, and Acetyl-L-carnitine playing the central role.

Central nervous system acting agents like Flumazenil and Dopamine agonists may also be used.

Ammonia scavenging agents as L-ornithine L-aspartate (LOLA); Ornithine phenylacetate, phenylbutyrate, and sodium benzoate; Spherical carbon microsphere adsorbent (AST-120); Polyethylene glycol 3350-electrolyte solution; and Molecular absorbent recirculating system (MARS) also benefits in HE.

Furthermore, vascular/interventional management as Embolization of portosystemic shunts may be a helpful treatment option in a select group of patients with refractory HE.

Hoilat GJ, Suhail FK, Adhami T, John S. Evidence-based approach to the management of hepatic encephalopathy in adults. World J Hepatol 2022; 14(4): 670-681