Am J Gastroenterol
New ACG guidance sharpens treatment strategy for hepatic encephalopathy
Clinical Takeaway: Start and titrate lactulose early for overt hepatic encephalopathy; add rifaximin for acute episodes or recurrence, and stop chasing ammonia levels to guide therapy.
The American College of Gastroenterology (ACG) has released its first comprehensive clinical guideline dedicated to hepatic encephalopathy (HE), offering 24 evidence‑graded recommendations that emphasize practical, patient‑centered management across inpatient and outpatient settings.
Lactulose remains the cornerstone. For overt HE, the guideline recommends lactulose to improve outcomes and prevent recurrence. After a first episode, clinicians should continue outpatient lactulose, titrated to 2–3 soft bowel movements daily, using stool frequency and the Bristol Stool Scale to reduce readmissions. High‑volume polyethylene glycol (PEG) is suggested as an inpatient alternative when rapid catharsis is needed.
Rifaximin use is clarified. In acute overt HE, the panel suggests adding rifaximin to lactulose rather than lactulose alone. For prevention, outpatient rifaximin is suggested in patients with cirrhosis and overt HE to reduce recurrence, and recommended as add‑on therapy for patients with recurrent episodes despite lactulose.
What not to do: The guideline discourages routine serum ammonia testing to diagnose or guide treatment, citing poor correlation with clinical status. Likewise, routine brain imaging is not recommended in cirrhosis patients with confusion but no focal neurologic deficits.
Covert/minimal HE: For suspected minimal or covert HE, a single validated cognitive test is favored over combination strategies, and lactulose may be considered vs. no treatment; however, evidence is insufficient to endorse routine therapy solely to prevent overt HE.
“Hepatic encephalopathy continues to be a big burden for patients and not only patients, but also family members,” lead author Jasmohan S. Bajaj, MD, noted, emphasizing the guideline’s focus beyond the clinic and toward real‑world care gaps.
Overall, the new ACG guidance tightens drug‑therapy decisions, promotes high‑value care, and offers clinicians a clearer, more actionable roadmap for managing this common and costly complication of cirrhosis.
Source: Bajaj JK, et al. (2026, March 1). Am J Gastroenterol. ACG Clinical Guideline: Hepatic Encephalopathy