Hepatic encephalopathy (HE) is a brain problem caused by serious liver disease. When the liver cannot clear waste from the blood properly, thinking, alertness, and behaviour can change.
In March 2026, the American College of Gastroenterology (ACG) published its first full guideline on HE. It has 24 recommendations covering diagnosis, treatment, prevention, nutrition, and transplant.
This article explains the main points in plain language, and what they may mean for families caring for someone with cirrhosis.
Read More: Best Liver Transplant Treatment in Delhi
Key Findings from the Guideline
- Blood ammonia alone should not be used to diagnose the early, hidden form of HE or to guide treatment
- Lactulose stays the first-line medicine, and doctors are advised to adjust it using stool quality, not just a fixed dose
- Rifaximin, an antibiotic, is suggested alongside lactulose early in an acute episode, and to prevent repeat episodes
- Routine brain scans are not advised for confusion in cirrhosis unless there are new signs of a nerve or brain problem
- Nutrition, exercise, and transplant questions are covered too, not just medicines
What Is Hepatic Encephalopathy?
- HE ranges from very mild changes that need testing to spot, to obvious confusion, disorientation, and even coma
- Covert (or minimal) HE means subtle changes in attention or thinking that may not show in a routine chat
- Overt HE means clear, visible symptoms such as confusion, unusual sleepiness, or a flapping hand tremor
- It usually happens in people with cirrhosis (advanced liver scarring), and it can come back after an episode
How the Guideline Was Developed
- A panel of liver and digestive-disease specialists reviewed the published evidence on HE
- They wrote 24 recommendations, each rated as strong or conditional, and each labelled by how certain the evidence is
- Many recommendations are “conditional” or based on low-certainty evidence, which means research is still limited in places
What Did the Guideline Recommend?
Diagnosis
- Ammonia is not a stand-alone test. A normal ammonia level in a confused patient should prompt doctors to look for other causes, not rule out HE
- One test, not two, is suggested when checking for covert HE
- Routine brain imaging is not advised for confusion in cirrhosis, unless there are new focal signs, seizures, or no response to treatment
- Look-alike conditions such as sleep apnoea, alcohol effects, and memory disorders should be checked for
Treatment
- Lactulose is recommended for overt HE, and suggested for covert HE. It is a syrup that acts as a laxative and helps the body clear waste through the bowel
- A high-volume polyethylene glycol (PEG) solution is a suggested alternative in acute overt HE
- Rifaximin is suggested in addition to lactulose during an acute episode
Preventing Repeat Episodes
- After a first overt episode, lactulose is recommended, adjusted to about 2–3 soft bowel movements a day
- The Bristol Stool Scale, a simple chart of stool types, is suggested to help adjust the dose at home
- Rifaximin is suggested for prevention, and recommended when episodes come back despite lactulose
- Zinc is suggested only for people with low blood zinc whose symptoms persist
After TIPS
- TIPS is a procedure that redirects blood flow in the liver to lower pressure in its veins
- Before a planned TIPS, rifaximin is recommended starting 14 days ahead and continuing for at least 6 months
Nutrition and Transplant
- A specialist summarising the guideline noted a late-night snack is recommended, and amino-acid supplements may help if protein needs cannot be met by diet
- Exercise is described as beneficial
- The guideline also addresses transplant considerations for people with HE
What This Means for Patients
- This is an official, published clinical guideline, not early-stage research
- Families may hear their team talk less about “the ammonia number” and more about symptoms, stool pattern, and triggers such as infection or bleeding
- Good to know:
- Do not change lactulose or other medicines on your own. Doses are adjusted with the treating team
- Some recommendations rest on low-certainty evidence
- The guideline is written for doctors, and individual care can differ
When to Speak With a Specialist
Talk to a liver specialist if you or a family member with cirrhosis:
- Has new confusion, unusual sleepiness, or changes in behaviour. Sudden confusion needs urgent medical attention
- Has had HE more than once, even on treatment
- Is unsure why ammonia levels are being used, or not used, to guide care
- Is being considered for TIPS
- Wants to understand whether repeat HE should prompt a liver transplant evaluation, or wants a second opinion
Read More: Signs You May Need a Liver Transplant
Future Research and Next Steps
- The guideline notes that several treatments, such as stool-transplant approaches, should stay inside clinical trials for now
- More high-quality trials are needed on early, covert HE and on how to fit testing into busy clinics
Conclusion
The 2026 ACG guideline shifts HE care toward symptoms, careful treatment adjustment, and early prevention of repeat episodes. For families, the most useful step is a clear conversation with the liver team about triggers, medicine adjustment, and when transplant should be discussed.
How ConsultGrab Helps You
Living with cirrhosis can feel overwhelming. ConsultGrab supports patients and families with:
- Understanding your case in detail and explaining treatment options clearly
- Connecting you with relevant liver specialists and hepatologists
- Guidance on liver treatment and liver transplant consultation, from evaluation onward
- Support throughout the process, so you do not have to navigate it alone
Medical Disclaimer: This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.
Frequently Asked Questions (FAQs)
Hepatic encephalopathy is a change in thinking, alertness, or behaviour caused by serious liver disease, most often cirrhosis. It ranges from subtle changes found only on testing to obvious confusion and coma. It can return after an episode, so prevention matters.
Not on its own. The 2026 ACG guideline advises against using ammonia alone to diagnose covert HE or guide treatment. A normal level in a confused patient should also prompt doctors to look for other causes.
Lactulose is a syrup that works as a laxative and is the first-line medicine for hepatic encephalopathy. The guideline suggests adjusting it to about 2–3 soft bowel movements a day. Doses should only be changed with the treating team.
Yes. The guideline suggests adding rifaximin to lactulose in acute overt HE, and using it to prevent repeat episodes. It also recommends it before and after a planned TIPS procedure, with your doctor deciding what fits your case.
Routine brain imaging is not advised if there are no new signs of a brain or nerve problem. A scan may be needed with seizures, new focal signs, or no response to treatment. This decision belongs to the treating doctor.
Original Research Source
This article is based on findings from a clinical guideline and related media reporting.
Primary Research: ACG Clinical Guideline: Hepatic Encephalopathy, American Journal of Gastroenterology (2026)
Media Coverage: Medical Xpress: Recommendations presented for management of hepatic encephalopathy · HCPLive: ACG issues new hepatic encephalopathy guidelines
The content has been independently rewritten, analyzed, and simplified for educational purposes to help patients and families better understand the research findings.
