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Hepatic Encephalopathy in Alcohol-related Cirrhosis:a Systematic Review of Clinical Characteristics, Therapeutic Strategies, and Prognostic Outcomes

Year: 2026

Type: review

Abstract: BACKGROUND: Hepatic encephalopathy (HE) is a major complication of cirrhosis; however, its characterization in alcohol-related cirrhosis (ARC) remains limited because most available evidence derives from mixed-etiology cohorts. METHODS: A systematic review was conducted according to PRISMA 2020 guidelines. PubMed, EMBASE, and LILACS were searched through April 2026. Randomized controlled trials and cohort studies involving adults with ARC or documented alcohol consumption reporting HE-related outcomes were included. Risk of bias was assessed using the Cochrane RoB 2.0 tool and the Newcastle-Ottawa Scale, while certainty of evidence was evaluated using the GRADE framework. Due to substantial heterogeneity, a narrative synthesis was performed. RESULTS: Fourteen studies involving 6,185 participants were included. HE was associated with a hospital prevalence of 18.5% and a 90-day mortality of 12.1%. Observational evidence suggested that HE was associated with increased mortality (HR 3.1 at 90 days; HR 2.9 at 1 year), while active alcohol consumption was identified as a potential adverse prognostic factor (HR 2.5). For secondary prophylaxis, rifaximin was associated with reduced recurrence (HR 0.42), predominantly as add-on therapy to lactulose. Lactulose also reduced recurrence compared with placebo. In acute HE, polyethylene glycol demonstrated faster clinical improvement than lactulose, although evidence was limited. CONCLUSION: Available evidence suggests that HE in alcohol-related cirrhosis may represent a clinically relevant subgroup with potentially distinct prognostic characteristics. However, current evidence remains indirect, heterogeneous, and largely derived from mixed-etiology populations, precluding definitive conclusions regarding a specific alcohol-related HE phenotype. Dedicated prospective studies are needed.

Source: Arquivos de Gastroenterologia

DOI: 10.1590/s0004-2803.24612026-066

Authors: Gilberto JARAMILLO-TRUJILLO, Juan Sebastián FRÍAS-ORDOÑEZ, Hernando MARULANDA-FERNANDEZ, William OTERO-REGINO, Jorge Armando MEJÍA-TOBAR

Institutions: Universidad Nacional de Colombia, Fundación Cardiovascular de Colombia, Central Police Hospital

Language: English

Topic: Liver Disease and Transplantation

Subfield: Hepatology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: diamond

OpenAlex ID: W7224849781