**6. Treatment**

HE treatment has evolved over the last 5 decades and medical science had seen many breakthroughs during this tenure. Treatment can be tailored around multiple key management principles which parallel the pathophysiology of the disease and these principles are:(42)

gait

Tremor and incoordination

Oculocephalic reflex

Asterixis, Speech abnormalities, Ataxic

Nystagmus, Clonus, Muscular rigidity

**Grade Intellectual function Neuromuscular function** 

4 Stupor and Coma Unresponsiveness to noxious stimuli,

Neuropsychometric evaluation usually is done via 'paper and pencil tests' and 'computerized tests'. The routinely used paper and pencil tests include psychometric HE scores (PHES) and The Repeatable Battery for the Assessment of neurological status (RBANS). PHES has been endorsed as a 'gold standard' for diagnosis of MHE and is used to diagnose the cognitive changes that characterize MHE. RBANS in addition to diagnosing the cognitive issues, also scores patient's memory.(45) Some computerized psychometric tests like 'The inhibitory control test' and 'CDR computerized assessment system' are gaining popularity as promising diagnostic tests due to their effectiveness and convenience(46). However, the value of these psychometric tests is limited by methodological problems, training and education, demographic dependence and lack of

Neurophysiological assessment is done via Electroencephalography (EEG) and the Critical flicker frequency test (CFF). EEG is associated with decreased electrical activity and shows diffuse slowing of alpha waves with eventual development of delta waves.(47) CCF, a light based test, is used for a rapid and reliable quantification of HE. Based on the principle of hepatic retinopathy, it represents the frequency at which discrete light pulses are first perceived by the patient. A CCF of below 39 Hz is diagnostic for MHE and the test results

Imaging Modalities include different Magnetic resonance techniques( T1-weighted imaging, proton spectroscopy, magnetic transfer ratio, T2- weighted FLAIR sequence and diffusion weighted imaging) to measure cerebral edema, changes in brain activity and concentration of different substances( i-e glutamine, choline). A CT scan can be used to exclude subdural

HE treatment has evolved over the last 5 decades and medical science had seen many breakthroughs during this tenure. Treatment can be tailored around multiple key management principles which parallel the pathophysiology of the disease and these

0 Normal Minor abnormalities

deficits, irritability, depressed state

cognitive dysfunction, lethargy,

1 Personality changes, attention

2 Changes in sleep-wake cycle,

behavioral changes

3 Disorientation, unconsciousness,

Table 1. West Haven classification for grading of HE(1)

are not dependent on sex, occupation and education level.(48)

hematoma or other cerebrovascular events that may mimic HE.(48)

amnesia

standardization.(43)

**6. Treatment** 

principles are:(42)

Management of precipitating factors,

Reduction of ammonia

Modulation intestinal flora

Modulation of neurotransmission

Correction of nutritional deficiencies

Reduction of inflammation/infection

Many treatment options are available for the treatment of HE with the mainstay to eliminate the underlying factors that precipitate HE. It is recommended that all patients should receive the empiric therapy (Box C) for HE, based on the principle of reducing the production and absorption of ammonia. Some strategies that are commonly applied to stop precipitating events are the following:


Box C. Empiric Treatment for Hepatic encephalopathy(48)
