EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

Montagnese, Sara; Rautou, Pierre‐Emmanuel; Romero–Gómez, Manuel; Larsen, Fin Stolze; Shawcross, Debbie L.; Thabut, Dominique; Vilstrup, Hendrik; Weißenborn, Karin

doi:10.1016/j.jhep.2022.06.001

Cited by 181 publications

(180 citation statements)

References 190 publications

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“…Rifaximin is currently approved for the treatment of hepatic encephalopathy, and its use is supported by data showing an overall improvement in intestinal permeability, bacterial translocation, and endotoxemia ( 119 , 120 ). Preclinical studies have investigated the possible mechanisms.…”

Section: Future Treatment Options For Nafld/mafld: Efficacy Comes Thr...mentioning

confidence: 99%

Gut microbiota modulation in patients with non-alcoholic fatty liver disease: Effects of current treatments and future strategies

Maestri

Santopaolo²,

Pompili³

et al. 2023

Front. Nutr.

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Non-alcoholic fatty liver disease (NAFLD) is frequently associated with metabolic disorders, being highly prevalent in obese and diabetic patients. Many concomitant factors that promote systemic and liver inflammation are involved in NAFLD pathogenesis, with a growing body of evidence highlighting the key role of the gut microbiota. Indeed, the gut-liver axis has a strong impact in the promotion of NAFLD and in the progression of the wide spectrum of its manifestations, claiming efforts to find effective strategies for gut microbiota modulation. Diet is among the most powerful tools; Western diet negatively affects intestinal permeability and the gut microbiota composition and function, selecting pathobionts, whereas Mediterranean diet fosters health-promoting bacteria, with a favorable impact on lipid and glucose metabolism and liver inflammation. Antibiotics and probiotics have been used to improve NAFLD features, with mixed results. More interestingly, medications used to treat NAFLD-associated comorbidities may also modulate the gut microbiota. Drugs for the treatment of type 2 diabetes mellitus (T2DM), such as metformin, glucagon-like peptide-1 (GLP-1) agonists, and sodium-glucose cotransporter (SGLT) inhibitors, are not only effective in the regulation of glucose homeostasis, but also in the reduction of liver fat content and inflammation, and they are associated with a shift in the gut microbiota composition towards a healthy phenotype. Even bariatric surgery significantly changes the gut microbiota, mostly due to the modification of the gastrointestinal anatomy, with a parallel improvement in histological features of NAFLD. Other options with promising effects in reprogramming the gut-liver axis, such as fecal microbial transplantation (FMT) and next-generation probiotics deserve further investigation for future inclusion in the therapeutic armamentarium of NAFLD.

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Section: Future Treatment Options For Nafld/mafld: Efficacy Comes Thr...mentioning

confidence: 99%

Gut microbiota modulation in patients with non-alcoholic fatty liver disease: Effects of current treatments and future strategies

Maestri

Santopaolo²,

Pompili³

et al. 2023

Front. Nutr.

View full text Add to dashboard Cite

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“…Eight years later, the term subclinical HE was introduced and several definitions have followed since then. The latest classification combines MHE with grade I HE (according to West Haven criteria) under the term “covert” HE [ 7 ].…”

Section: Minimal Hepatic Encephalopathymentioning

confidence: 99%

“…Albumin administration determined MHE reversal and improved quality of life, probably through improved endothelial dysfunction [ 87 ]. Finally, given the beneficial effects of therapies on MHE and as suggested by the most recent EASL guidelines, patients with MHE should be treated with nonabsorbable disaccharides and/or rifaximin, and, if effective, this may be an ex adiuvantibus criterion for diagnosis [ 7 ]. Supplementary Table S2 summarizes the published study on the treatment of MHE [ 8 , 42 , 70 , 71 , 73 , 74 , 76 , 80 , 81 , 82 , 83 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 ].…”

Section: Therapy Of Minimal Hepatic Encephalopathymentioning

confidence: 99%

Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities

Faccioli

Nardelli

Gioia

et al. 2022

JCM

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Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of “overt” HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.

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“…Cognition, which encompasses intellectual functions including thought, attention and intelligence as well as judgment and decision making, is altered at all grades of encephalopathy, with significant implications for patients with liver disease (Revlin 2013 ). The cognitive manifestations of liver disease have been described since Hippocrates (Amodio 2015 ) and remain a bedrock of disease assessment (Montagnese et al 2022 ).…”

Section: Cognition In Hepatic Encephalopathymentioning

confidence: 99%

Remote monitoring of cognition in cirrhosis and encephalopathy: future opportunity and challenge

Buckholz

Rosenblatt

2022

Metab Brain Dis

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Hepatic Encephalopathy (HE) is a critically important complication of chronic liver disease and portal hypertension, but especially in early covert stages remains underdiagnosed and a common cause of hospitalization and morbidity. Defined by often subtle neuropsychiatric changes, significant cognitive deficits have been extensively described. While traditional methods of assessment remain underutilized in practice and subject to significant confounding with other diseases, mobile technology has emerged as a potential future tool to provide simple and dynamic cognitive assessments. This review discusses the proliferation of cognitive assessment tools, describing possible applications in encephalopathy and the challenges such an implementation may face. There are significant potential advantages to assessing cognition in real time in order to aid early detection and intervention and provide a more realistic measurement of real-world function. Despite this, there are issues with reliability, privacy, applicability and more which must be addressed prior to wide proliferation and acceptance for clinical use. Regardless, the rapid uptake of mobile technology in healthcare is likely to have significant implications for the future management of encephalopathy and liver disease at large.

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EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

Cited by 181 publications

References 190 publications

Gut microbiota modulation in patients with non-alcoholic fatty liver disease: Effects of current treatments and future strategies

Gut microbiota modulation in patients with non-alcoholic fatty liver disease: Effects of current treatments and future strategies

Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities

Remote monitoring of cognition in cirrhosis and encephalopathy: future opportunity and challenge

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