When should we seek urgent care for hepatic encephalopathy?

Question

Hello doctor,

I hope you are well. I am writing to ask for advice about my father’s health. He is 61 and was diagnosed with overt hepatic encephalopathy four months ago. He is now on the transplant waitlist, and our family feels unsure about what to expect in the next few weeks.

Last week, his ammonia level was 98 µmol/L, and his MELD score was 24. He has had two episodes where he did not recognize us, was confused about where he was, and tried to get out of bed at night. His hepatologist prescribed lactulose three times a day, which has helped somewhat but not completely.

We want to understand if overt hepatic encephalopathy usually keeps getting worse until transplant, or if it can stay stable for a while. At a recent appointment, a neurologist mentioned “subclinical progression,” but we are not sure what that means for my father.

He also has ascites, which is being treated with Spironolactone.

Could you please help us with the following questions:

What signs or symptoms should make us seek emergency care right away?
How can families best manage this condition at home while waiting for a liver transplant?

Kindly help.

Thank you very much for your time and guidance.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

Hepatic encephalopathy does not always get worse steadily or predictably. Often, symptoms come and go, with times of improvement and decline. With the right treatment, some people stay fairly stable for weeks or even months while waiting for a transplant.

The term “subclinical progression” means there are subtle or less obvious changes in brain function, like slower thinking, trouble paying attention, or sleep problems. These changes might not be easy to notice, but they can still happen.

Even though your father’s ammonia levels are high, symptoms do not always match the number exactly. How he is feeling and functioning usually gives a better idea of his condition.

Lactulose is a good first treatment. The aim is usually to have two to three soft bowel movements each day. If this is not happening, changing the dose or adding medicines like rifaximin can help manage symptoms.

Worsening symptoms are often caused by things like infections, constipation, dehydration, or some medicines. Finding and managing these triggers can help prevent more episodes.

You should seek immediate help right away if you notice any of the following:

Difficulty in waking.
Inability to recognize family members.
Persistent agitation or confusion.
Fever.
Vomiting blood or passing black stools.

At home, make sure medications are taken regularly, keep up with fluids, watch bowel movements, and keep the environment safe to lower the risk of falls or injuries.

Management of ascites with Spironolactone is appropriate. However, do watch for signs such as increasing abdominal swelling or difficulty breathing, which should prompt medical review.

With careful monitoring and following the treatment plan, hepatic encephalopathy can often be managed and kept stable while waiting for a liver transplant.

I hope this helps.

Thank you.