Table 3.

Treatment strategies in patients with precipitant-induced episodic HE

General supportive care
	Prevention of falls or body harm in disorientated patients
	Care of bladder and bowel function
	Care of i.v. lines
	Monitor fluid balance
	Monitor glycaemia and electrolytes
	Monitor arterial blood gases
	Correct acid/base disturbances
	Monitor blood pressure
	Avoid aspiration pneumonia
	Prevent causes of sepsis
Support nutritional needs	An energy intake of 35-40 kcal /kg BW/d and a protein intake of 1.2-1.5 g/kg BW/d are recommended. Energy should be provided by glucose and fat in a ratio of 65-50: 35%-50% of non protein calories according to the ESPEN guidelines for nutrition in liver disease (31) In patients with severe hepatic encephalopathy (Grade III-IV), solutions with an increase content of BCAAs and reduced amount of aromatic amino acid can ameliorate neurological symptoms ensuring adequate protein intake
Treatment of the precipitating event
GI bleeding	Stop bleeding with vasoactive drugs, endoscopic therapy or angiographic shunt (TIPS) Correct anaemia with blood transfusion Nasogastric tube to facilitate upper GI cleansing
Infection (pulmonary, urinary tract, spontaneous bacterial peritonitis)	Appropriate antibiotic terapie
Exogenous sedatives	Discontinue benzodiazepines
Electrolyte abnormalities	Discontinue diuretics Correct hypo or hyperkalemia
Constipation	Cathartic Bowel enema
Deterioration of renal function	Discontinue diuretics Correct dehydration Discontinue nephrotoxic antibiotics