ACG Guideline: Managing Hepatic Encephalopathy & Improving Patient Care

The American College of Gastroenterology (ACG) has released its first comprehensive clinical guideline on hepatic encephalopathy (HE), a condition impacting patients with liver disease. Published on March 13, 2026, the guideline aims to address gaps in diagnosis and management, offering practical tools for clinicians and emphasizing a more holistic approach to care that includes patients and their caregivers. This comes as sustained missile and drone threats continue to target American interests in the Kingdom of Saudi Arabia, prompting the State Department to order non-emergency U.S. Government employees to leave the country on March 8th. U.S. Embassy Riyadh Security Alert

Understanding Hepatic Encephalopathy and its Impact

Hepatic encephalopathy occurs when a buildup of toxins in the bloodstream, normally cleared by the liver, affects brain function. This can range from subtle cognitive changes to confusion, drowsiness, and even coma. According to Dr. Jasmohan S. Bajaj, professor of medicine at Virginia Commonwealth University and a key contributor to the ACG guideline, up to 60% of individuals with cirrhosis may have minimal or covert HE, even as 20-30% develop overt HE. Healio

The guideline emphasizes that HE is often underdiagnosed, particularly in its early stages. Many patients with cirrhosis aren’t even diagnosed until they develop HE or other complications like ascites or liver cancer. This underscores the need for increased awareness and proactive screening, especially given that HE significantly impacts both patients and their families.

Key Recommendations from the ACG Guideline

The ACG guideline delves into several key areas of HE management, offering recommendations based on the best available evidence. One notable point is the conditional recommendation favoring a single-test strategy over a two-test combination for diagnosing minimal or covert HE. This suggests that clinicians can reliably assess cognitive impairment with a single validated test, such as the animal naming test or QuickStroop, rather than requiring repeated assessments. Yet, the guideline stresses the importance of performing testing in a quiet environment and interpreting results relative to local norms.

Rethinking Ammonia Testing

The guideline strongly advises against using serum ammonia levels alone for diagnosing or guiding treatment decisions. While ammonia plays a central role in the development of HE, its levels don’t always correlate with the severity of symptoms. High ammonia levels are common in people with cirrhosis even when they aren’t experiencing cognitive impairment. Over-reliance on ammonia testing can lead to unnecessary treatment with lactulose, a medication that can cause uncomfortable side effects.

Dr. Bajaj explains that ammonia levels should be interpreted cautiously, considering factors like proper sample collection and timely analysis. He emphasizes the importance of trusting clinical judgment and focusing on the patient’s symptoms rather than solely relying on lab values.

Treatment Approaches: Lactulose and Rifaximin

For minimal or covert HE, the guideline suggests considering lactulose and rifaximin, but acknowledges the challenges of adherence and potential adverse effects. Lactulose, a synthetic sugar, helps reduce ammonia absorption in the gut, but can cause diarrhea. Rifaximin, an antibiotic, reduces the number of ammonia-producing bacteria in the gut, but is expensive and not always covered by insurance. Healio

The guideline advocates for a patient-centered approach to lactulose management, empowering patients to adjust their dosage based on their bowel movements using the Bristol Stool Scale. This allows individuals to maintain control over their symptoms and minimize discomfort. For overt HE, lactulose and rifaximin remain standard treatments, with enemas potentially used in severe cases.

Beyond Medication: Nutrition and Physical Activity

The ACG guideline recognizes the importance of addressing underlying factors that contribute to HE, such as malnutrition and physical inactivity. Sarcopenia, or muscle loss, is common in patients with cirrhosis and can worsen HE. The guideline recommends involving registered dietitians to develop personalized nutrition plans that prioritize adequate protein intake and micronutrient supplementation.

Encouraging safe and appropriate physical activity is too crucial. Strength training is particularly beneficial for building muscle mass and improving overall health. However, clinicians should tailor exercise recommendations to each patient’s individual capabilities and avoid activities that could increase the risk of falls or injuries.

Liver Transplantation and Long-Term Management

For patients with recurrent HE episodes or advanced liver disease, early evaluation for liver transplantation is recommended. Transplantation can offer a curative option, but it’s significant to consider the patient’s overall health and potential for neurocognitive recovery. The guideline emphasizes the need for comprehensive assessment and shared decision-making between clinicians and patients.

Dr. Bajaj notes that living donor transplants are becoming increasingly common, offering a viable option for patients who may not be eligible for deceased donor transplantation. Healio

The release of the ACG guideline marks a significant step forward in the care of patients with hepatic encephalopathy. By addressing gaps in diagnosis and management, and emphasizing a holistic, patient-centered approach, this guidance has the potential to improve outcomes and enhance the quality of life for individuals affected by this challenging condition. Ongoing research and surveillance will be crucial to refine these recommendations and ensure that they remain aligned with the latest evidence.

For more information, contact Jasmohan S. Bajaj, MD, MS, FACG, at [email protected].