Welcome to Module 3

This module is introduced by Sara Montagnese, Full Professor of Medicine and Director of the Clinical Medicine Ward V (Hepatology) at Padova University Hospital, Italy, together with Chiara Mangini from Padova University Hospital, Italy.

They will guide you through the clinical presentation, diagnosis, and management of hepatic encephalopathy (HE), one of the most complex and clinically relevant complications of cirrhosis. Understanding how to recognize, diagnose, and treat HE is essential for improving patient outcomes and reducing hospitalizations.

Hepatic encephalopathy encompasses a broad spectrum of neurocognitive impairment, ranging from subtle cognitive dysfunction to coma. In clinical practice, the distinction between covert and overt forms of HE is particularly important. Covert hepatic encephalopathy (CHE), also referred to as minimal HE, includes any cognitive impairment that is not clinically overt and therefore requires specific testing for diagnosis. Among available tools, the Animal Naming Test (ANT) represents one of the simplest and most practical bedside tests to detect covert HE in routine clinical settings.

The module also emphasizes the importance of accurate clinical grading. Temporal disorientation is a key clinical feature and is sufficient to diagnose grade II overt hepatic encephalopathy (OHE). Recognizing this sign is critical, as grade II OHE represents a turning point that requires prompt treatment and careful monitoring.

You will also explore the role of ammonia in the diagnostic process. While elevated ammonia levels may support the diagnosis of HE, normal ammonia levels in a patient with acute encephalopathy should prompt consideration of alternative diagnoses. Acute encephalopathy with normal ammonia levels suggests a non–hepatic encephalopathy cause and requires further evaluation to identify other neurological or metabolic conditions.

Management strategies for HE will be discussed in detail, with a focus on optimizing treatment and preventing recurrence. Lactulose remains the cornerstone of therapy, and careful titration is essential to achieve optimal clinical response. In patients who experience recurrence, the addition of rifaximin represents an effective strategy to reduce further episodes and improve long-term outcomes.

Finally, the module addresses hepatic encephalopathy in the context of transjugular intrahepatic portosystemic shunt (TIPS). Post-TIPS hepatic encephalopathy is a common and challenging complication, and underdilation of TIPS is presented as a useful strategy to reduce the risk and severity of HE while preserving the benefits of portal decompression.

Through this module, you will gain a practical and clinically oriented understanding of hepatic encephalopathy, from early recognition to advanced management strategies, helping you make informed decisions in everyday clinical practice.

Upon completing Module 4, students will be able to:

• Diagnose and grade hepatic encephalopathy.
• Identify and treat precipitant factors.
• Use ammonia for diagnosis/differential diagnosis.
• Treat hepatic encephalopathy in different settings, including transjugular intrahepatic portosystemic shunt.