Hepatic Encephalopathy with Acute Decompensated Cirrhosis and Acute-on- Chronic Liver Failure

Hepatic encephalopathy (HE) is one of the major complications of cirrhosis, and recent evidence suggests that hospitalized cirrhotic HE patients with acute decompensation and, especially, acute-on-chronic liver failure (ACLF) have extremely poor outcomes (NEJM JW Gastroenterol Sep 2013 and Gastroenterology 2013; 144:1426). The current review article discusses the pathophysiology and management of such patients. Highlights are as follows:

• Although the exact mechanism of HE in these patients is unknown, systemic inflammation (from bacterial translocation, sepsis, and insulin resistance), interorgan ammonia trafficking, and oxidative stress, all modulated by glutaminase gene alteration, likely play key roles.

• Because HE in this setting is associ…