After reading and analyzing the article “Evaluation and management of emergencies in the patient with cirrhosis”, we wish to share our thoughts and comments on the theme. Hepatic encephalopathy (HE) is one of the main complications of cirrhosis. It consists of brain dysfunction, as a consequence of liver failure, and produces alterations at the subclinical level that can lead to coma. Thus, it is considered a medical emergency and should be treated immediately.1

Nonabsorbable disaccharides, such as lactulose and lactitol, are the first-line treatment. The article does not precisely state under which circumstances they should be used. Their administration depends on the grade of HE. In cases of grade I and potential grade II, oral administration is indicated, whereas in grades II, III, and IV, administration can be carried out through a nasogastric tube or by means of an enema, if the patient is unable to receive oral administration.2

Nonabsorbable antibiotics are of great use as an alternative to nonabsorbable disaccharides, and include neomycin, metronidazol, and rifaximin. Of those three, rifaximin is the most important, due to its current approval by the Food and Drug Administration. However, demonstrating its efficacy as adjuvant therapy is still greatly relevant. In addition, the study by Sharma et al. reinforces the information of the article. Those authors conducted a double-blind randomized trial, in which 120 patients with HE received only lactulose or lactulose plus rifaximin (1,200 mg/day). The patients that received the combined treatment had better HE resolution, as well as a statistically significant decrease in the number of days of hospital stay (5.8 + 3.4 vs 8.2 + 4.6 days, p 1/4 0.001), compared with the patients that received only lactulose.3

Intravenous L-ornithine L-aspartate (LOLA) can be added in patients that do not respond to conventional treatment. In a double-blind randomized trial, a higher improvement rate in grade of HE (92.5% vs 66%, P < .001), shorter recovery time (2.70 ± 0.46 vs 3.00 ± 0.87 days, P = .03), and a lower mortality rate (16.4% vs 41.8%, P = .001) were reported in patients that received the combination of LOLA, lactulose, and rifaximin, compared with patients that received placebo, lactulose, and rifaximin.4

Including the complementary administration of nonabsorbable disaccharides, according to HE classification, is suggested as a better approach. Likewise, the search for and/or carrying out of clinical trials that evaluate the efficacy of the different treatment combinations for HE is considered opportune, favoring rapid patient recovery and a reduced mortality rate.