How to treat hepatic encephalopathy in my grandpa, who is 74?

Question

Hello doctor,

My grandfather, who is 74, was recently diagnosed with overt hepatic encephalopathy on top of his long-standing NASH-related cirrhosis. He had a large GI bleed last month, which we were told probably triggered the encephalopathy episode. The hospital managed the bleed, but he has been very slowed down mentally since then, slow to respond, shuffling when he walks, and sometimes picking at things that aren't there.

His doctors are talking about a TIPS procedure, but we have read that TIPS can actually worsen encephalopathy. He is currently not on any preventive medication for OHE. We are wondering if he should be started on something like Rifaximin to help prevent future episodes, especially if he gets the TIPS.

Also, his creatinine has been creeping up, and we are worried about hepatorenal syndrome. What are the most important things to monitor and do at this stage?

Please advise.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I can understand your concern.

Your grandfather has overt hepatic encephalopathy (HE) triggered by a GI (gastrointestinal) bleed, which is a common and serious precipitating factor. Blood in the gut increases ammonia production, worsening brain dysfunction. His slowed thinking, shuffling gait, and picking behavior are typical features of HE.

Preventive treatment is essential now. He should be on lactulose lifelong, adjusted to produce two to three soft stools daily, and Rifaximin is strongly recommended after any overt HE episode to reduce the risk of recurrence by about 50 to 60 percent, especially if a TIPS (transjugular intrahepatic portosystemic shunt) procedure is planned. Regarding TIPS, it helps control bleeding and ascites but can increase the risk of HE because more toxins bypass the liver; however, preventive treatment with lactulose and Rifaximin can significantly reduce this risk.

Kidney function is also critical, and rising creatinine may signal early hepatorenal dysfunction. Creatinine, urine output, sodium levels, mental status, and signs of dehydration or infection should be closely monitored. The most important daily priorities are strict medication adherence, preventing constipation, maintaining hydration, avoiding sedatives, monitoring for confusion or sleep changes, and seeking urgent care if mental status worsens.

Early prevention and careful monitoring can significantly improve stability and quality of life.

I hope this helps.

Take care.