How to treat recurrent HE in a 71-year-old woman?

Question

Hello doctor,

I am the daughter of a 71-year-old woman who has cirrhosis due to chronic hepatitis B and has experienced overt hepatic encephalopathy episodes three times this year, with the most recent episode occurring last week.

After the latest episode, she returned home, but she is not quite back to normal. She is confused about dates, her handwriting has become shaky, and she is not recognizing some family members reliably. Her hepatologist confirmed that this might be persistent or recurrent overt hepatic encephalopathy.

She is on Entecavir for hepatitis B, and her HBV DNA is undetectable, which is reassuring. However, her liver function remains poor:

ALT: 88 U/L
AST: 112 U/L
Bilirubin: 3.8 mg/dL
INR: 2.1

Her cardiologist is managing her atrial fibrillation with Rivaroxaban, which is causing a lot of anxiety because of the bleeding risk, given her poor liver function and elevated INR.

Her nephrologist recently started Terlipressin for early hepatorenal syndrome. My mother has also fallen twice this month at home, and her orthopedic doctor said her bone density is very low due to osteoporosis related to chronic liver disease.

The combined burden of the overt hepatic encephalopathy episodes, the falls, the kidney issue, and the heart condition is overwhelming for all of us as caregivers. She has been referred to palliative care, which frightened us greatly.

Is there still active treatment available to reduce overt hepatic encephalopathy recurrence at this stage?
How do we balance quality of life with all these overlapping conditions?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Your mother has advanced liver cirrhosis related to chronic hepatitis B, and the repeated episodes of hepatic encephalopathy indicate that her liver function is significantly impaired.

The confusion, handwriting changes, and difficulty recognizing family members can occur when toxins such as ammonia affect brain function, and recovery after severe episodes may take days to weeks, sometimes leaving mild, persistent cognitive changes.

It is encouraging that her hepatitis B is well controlled with Entecavir, which helps prevent further viral damage.

To reduce the recurrence of encephalopathy, long-term therapy typically includes Lactulose (adjusted to maintain about two to three soft stools daily) and often Rifaximin, which decreases ammonia-producing gut bacteria.

Preventing triggers is also crucial. These include

Infections.
Constipation.
Dehydration.
Bleeding.
Kidney dysfunction.

Her treatment for early hepatorenal syndrome with Terlipressin is part of managing these complications.

The involvement of palliative care can sound alarming, but it does not mean treatment is stopping. In advanced liver disease, palliative care teams help manage symptoms such as

Confusion.
Fatigue.
Falls.
Emotional stress while coordinating care among specialists.

Their goal is to improve comfort, safety, and quality of life alongside active medical treatment.

Because she has atrial fibrillation and is taking Rivaroxaban, careful monitoring for bleeding is essential, particularly given her elevated INR (international normalized ratio) and risk of falls. Bone health and fall prevention should also be addressed due to osteoporosis.

In many cases, careful medication adherence, prevention of triggers, nutritional support, and close follow-up with hepatology can reduce the frequency of encephalopathy episodes. Discussions with her care team about the overall goals of care will help balance ongoing treatment with maintaining the best possible daily functioning and safety.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.