1 Cognitive dysfunction in patients with cirrhosis may also be related to intracranial events, metabolic abnormalities, and sepsis. The decision whether to hospitalize and whether

to admit to the floor or the intensive care unit depends on the precipitating factor and ability to control the airway. There should be a low threshold for endotracheal intubation to prevent aspiration, especially in those patients with concurrent gastrointestinal bleeding.2 Once these decisions are taken, the next question to be answered is: what is the precipitating factor? Precipitating factors are identifiable in 97% of patients with episodic HE and in more than 70% with persistent HE; multiple PD-1 antibody factors may coexist. Although not specifically evaluated in trials, correction of precipitating factors is considered

first-line therapy for HE. These include controlling bleeding and infections and correction of metabolic abnormalities. Prevention of falls or body injuries in disoriented patients and supportive care are essential. Maintenance of adequate nutrition with energy intake of 35-40 kcal/kg/day and protein intake of 1.2-1.5 g/kg/day are recommended, and protein should not be avoided.3 The specific pharmacological treatments CP-690550 molecular weight are directed toward the reduction of ammonia production, and increase in fixation and/or excretion of ammonia.1 The majority of therapeutic options currently in use are directed toward reducing ammonia production from the gut, with lactulose and rifaximin being the most widely used agents. These drugs are associated with mental status improvement but as precipitating factors are simultaneously being corrected, it is difficult to pinpoint the true reason for improvement. Lactulose can be given as an STK38 enema in patients unable to take medications by mouth. Because patients with

an episode of HE are at risk of developing subsequent episodes, prevention of recurrence of HE is essential. Recently the results of several randomized trials have became available. Patients enrolled had differing risk factors for HE such as TIPS or those who experienced a recent episodes of overt HE, and those with recurrent episodes.3-6 The prophylactic efficacy of lactitol, rifaximin, lactulose, and a low-protein diet have been tested.3-7 The multicenter study of rifaximin versus placebo in patients with at least two prior HE episodes demonstrated a significant reduction in HE episodes as well as hospitalizations in the rifaximin group.6 In patients randomized to either lactulose or placebo after their first episode of HE, lactulose significantly decreased the incidence of recurrence of HE.5 A multicenter Spanish study, still in abstract form, did not find any difference in recurrent HE episodes in patients randomized to either a long-term normal protein diet (although enhanced with branched-chain amino acids) or a low-protein diet.