23. Neomycin is an alternative choice for treatment of OHE (GRADE II-1, B, 2). 24. Metronidazole is an alternative choice for treatment of OHE (GRADE II-3, B, 2). There are no randomized, placebo-controlled trials of lactulose for maintenance Regorafenib datasheet of remission from OHE. However, it is still widely recommended and practiced. A single-center, open-label RCT of lactulose demonstrated less recurrence

of HE in patients with cirrhosis.[33] A recent RCT supports lactulose as prevention of HE subsequent to upper gastrointestinal (GI) bleeding.[110] Rifaximin added to lactulose is the best-documented agent to maintain remission in patients who have already experienced one or more bouts of OHE while on lactulose treatment after their initial episode of OHE.[101] Once TIPS was popularized to treat complications of PH, its tendency to cause the appearance of HE, or less commonly, intractable persistent HE, was noted. Faced with severe HE as a complication of a TIPS procedure, physicians had a major dilemma. Initially, it was routine to use standard HE treatment to prevent post-TIPS HE. However, one study illustrated that neither rifaximin nor lactulose prevented post-TIPS HE any better than GW-572016 placebo.[111] Careful case selection has reduced the incidence

of severe HE post-TIPS. If it occurs, shunt diameter reduction can reverse HE.[112] However, the original cause for placing TIPS may reappear. Another important issue with TIPS relates to the desired portal pressure (PP) attained after placement of stents. Too low a pressure because of large stent diameter can lead to intractable HE, as noted above. There is a lack of consensus on whether to aim to find more reduce PP by 50% or below 12 mmHg. The latter is associated with more bouts of encephalopathy.[113] It is widely

used to treat post-TIPS recurrent HE as with other cases of recurrent HE, including the cases that cannot be managed by reduction of shunt diameter. Recurrent bouts of overt HE in patients with preserved liver function consideration should lead to a search for large spontaneous PSSs. Certain types of shunts, such as splenorenal shunts, can be successfully embolized with rapid clearance of overt HE in a fraction of patients in a good liver function status, despite the risk for subsequent VB.[114] 25. Lactulose is recommended for prevention of recurrent episodes of HE after the initial episode (GRADE II-1, A, 1). 26. Rifaximin as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after the second episode (GRADE I, A, 1). 27. Routine prophylactic therapy (lactulose or rifaximin) is not recommended for the prevention of post-TIPS HE (GRADE III, B, 1). There is a nearly uniform policy to continue treatment indefinitely after it has successfully reversed a bout of OHE. The concept may be that once the thresholds for OHE is reached, then patients are at high risk for recurrent episodes.