ACG 2026 Hepatic Encephalopathy Update

What Emergency & Acute Care Teams Must Change—Starting Tomorrow

Hepatic encephalopathy (HE) is no longer a “late complication.” It is now the most common first decompensating event in cirrhosis—driving ED visits, ICU admissions, readmissions, caregiver burden, and mortality.

The 2026 ACG Clinical Guideline reframes HE as a systems disease, not just a biochemical one. When combined with ACC 2022 ICU care principles, it demands a shift in how we triage, investigate, and treat these patients.

1. HE Is Not “Just Ammonia”

The Three Villages + Five Axes Framework

The guideline introduces a conceptual model that should anchor bedside thinking:

“Three Villages of HE”

• Village 1 – Pathogenesis (gut–brain axis, inflammation, ammonia, sarcopenia)

• Village 2 – Impact (patients, caregivers, healthcare systems)

• Village 3 – Multidisciplinary care (ED, hepatology, ICU, rehab, social systems)

HE is now classified across five axes:

1. Type (A/B/C)

2. Severity (West Haven)

3. Time course

4. Precipitated vs non-precipitated

5. Social infrastructure (NEW)

👉 Game changer:
You must now ask:

“Can this patient actually survive outside the hospital?”

• Covert HE → Overt HE → Recurrent admissions → Cognitive decline

• ED clinicians often see patients too late in this curve

2. Covert/Minimal HE (CHE/MHE): The Missed Diagnosis in ED

Who should trigger suspicion?

• Hypoalbuminemia

• Decompensated cirrhosis

• Portal hypertension/shunts

• Falls, traffic violations, navigation issues

• Subtle cognitive complaints

👉 Key ED pearl:
Isolated asterixis ≠ OHE

How to test (NOT ammonia)

• Single-test strategy (ACG recommendation)

• Practical tools:

  • Stroop / EncephalApp

  • Animal Naming Test

  • Critical Flicker Frequency

❌ Do NOT use ammonia to diagnose CHE

Treatment: “Theragnostic trial”

• Lactulose (4–8 week trial)

• Reassess cognition + function

Useful in ED follow-up planning and liaison clinics

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3. “Is This Really HE?” — The Cognitive Differential

“Cirrhosis + Cognitive Complaint Pathway”

More than 50% of suspected HE ≠ HE

Common mimics:

• Dementia / MCI

• Depression / PTSD

• Obstructive sleep apnea

• Substance use

• Metabolic/endocrine disorders

👉 ED shift:
Stop reflex lactulose escalation → start structured differential evaluation

4. Overt HE in ED & ICU

Triage: Who Needs Admission?

“Admission Decision Flowchart”

Admit if:

• Grade 3–4 HE

• First episode

• Infection, bleed, AKI

• Poor social support

Strong Recommendations That Change Practice

• Lactulose for OHE (strong)

• Secondary prophylaxis after first episode (strong)

• Add rifaximin for recurrence (strong)

• Protein 1.2–1.5 g/kg/day (strong)

• Branched Chain Amino Acid (BCAA) —> if needed (strong)

• Rifaximin pre-TIPS (strong)

🚨 What to STOP Doing

• Routine ammonia testing

• Routine CT brain without focal deficit

👉 A normal ammonia ≠ no HE
👉 HE = clinical diagnosis of exclusion

5. Acute Management: ED + ICU Integration (ACG 2026 + ACC 2022)

Acute HE Treatment Algorithm

First-line (ED + ICU)

Lactulose

• Oral/NG: every 1–2 hrs → 2–3 soft stools

• Enema if needed

⚠️ Avoid overuse → dehydration, hypernatremia

See more about Lactulose in HE, here

PEG (Alternative)

• Faster resolution in trials

• Useful if ileus/bloating

Rifaximin

• Add in recurrent HE

• Consider early in severe ICU cases

ACC 2022 ICU Principles (Add These to Your Workflow)

Airway & Neuroprotection

• Intubate if:

  • GCS ≤ 8

  • Aspiration risk

• Avoid oversedation (benzodiazepines worsen HE)

Hemodynamic & Metabolic Targets

• Maintain MAP ≥ 65 mmHg

• Correct:

  • Hypokalemia

  • Hyponatremia

  • Hypoglycemia

Infection Control

• Low threshold for antibiotics

• Sepsis = major precipitant

ICP & Cerebral Edema (Severe HE / ACLF)

• Head elevation

• Avoid hypercapnia

• Consider hypertonic saline if needed

Nutrition (Critical Update)

• DO NOT restrict protein

• ICU patients may need up to 2 g/kg/day

6. Nonresponse at 48–72 Hours

📌 Insert Figure 9 here – “Nonresponse Algorithm”

If not improving:

1. Reconsider diagnosis

2. Re-look for precipitants

3. Evaluate for:

   • TIPS

   • Large shunts

👉 Do NOT just increase lactulose blindly

7. Preventing Recurrence

“Recurrence Prevention Pathway”

Core Strategy

• Lactulose (target 2–3 stools/day)

• Rifaximin (↓ recurrence 58%)

System-Level Changes

• Use Bristol stool scale

• EMR alerts/order sets

• Patient education tools

Deprescribing (Critical ED Role)

Stop/minimize:

• Benzodiazepines

• Opiates

• Gabapentinoids

• Z-drugs

• PPIs (when inappropriate)

Nutrition & Sarcopenia

• Protein: 1.2–1.5 g/kg/day

• Late-night snack

• Exercise programs

👉 Muscle = ammonia buffer

8. TIPS, Refractory HE & Transplant

TIPS-related HE

• Start rifaximin 14 days before TIPS

• Continue ≥ 6 months

Refractory HE

• Consider:

  • Shunt embolization

  • TIPS revision

Transplant Implications

• HE underestimates MELD risk

• Consider transplant even at low MELD

👉 Early referral if:

• Recurrent HE

• Grade III–IV

• Persistent cognitive decline

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References

1. Bajaj JS, Jakab SS, Jesudian AB, et al. ACG Clinical Guideline: Hepatic Encephalopathy. Am J Gastroenterol. 2026;121:588-618. doi:10.14309/ajg.0000000000003899

2. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic Encephalopathy in Chronic Liver Disease: 2022 Practice Guidance. Hepatology. 2022;76(3):1027-1040. doi:10.1002/hep.32477