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Cognitive Impairment in Liver Disease

Hepatic encephalopathy (HE) encompasses a range of neuropsychiatric abnormalities in patients with significant liver disease. This chapter describes recently agreed upon terminology, current thoughts on the pathogenesis of HE, and an approach to the treatment of this disorder. The spectrum of symptoms with mild cognitive and attention deficits are now described as covert HE; more severe symptoms, such as personality changes, intellectual impairment, and depressed level of consciousness, are defined as overt HE. The precise mechanisms involved in the pathogenesis of HE are not completely established despite its association with elevated blood ammonia levels. The rationale for treatment of HE depends on controlling the blood ammonia levels; however, other substances may also play an important role in the pathogenesis of HE. The chapter discusses the important principles involved in the treatment of overt HE, which consists of a four-pronged approach: identification and correction of clinical precipitants, recognition and management of coexisting medical conditions, empiric treatment of overt HE, and care of the unconscious patients. The chapter also discusses new therapies, such as addition of rifaximin to lactulose treatment for grade 3 and 4 overt HE and polyethylene glycol therapy. Patients with more advanced liver disease or with recurrent episodes of overt HE are generally treated with liver transplantation.