Diagnostic approach to persistent hepatic encephalopathy

Hepatic encephalopathy (HE) is a complication of cirrhosis manifested by neuropsychiatric and neuromuscular changes with impact on quality of life. Clinical picture ranges from normal physical exam to stupor and coma. In persistent HE, patient never becomes free of HE.

To review medical literature searching for evidence concerning persistent HE and nonclassical factors involved in its development.

We identified articles by searching PubMed (1966 to January 2011), EMBASE (1980 to January 2011) and Pubgle. Relevant articles with the terms persistent AND hepatic AND encephalopathy were selected. Precipitating factors of this clinical picture were recorded.

Many factors lead to HE and contribute to its persistence. The most common are gastrointestinal bleeding, spontaneous bacterial peritonitis and high protein intake. Other non-classical factors such as porto-systemic shunts, small bowel bacterial overgrowth, H. pylori infection and anemia must be considered. Identification and correction of these factors improves morbidity and mortality.

It is important to recognize HE precipitants other than classical to provide the pathophysiological basis to understand persistent HE.