- HE in alcohol-related cirrhosis: hospital prevalence 18.5% and 90-day mortality 12.1%, with increased mortality (HR ~3.1 at 90 days, HR ~2.9 at 1 year).
- Active alcohol consumption identified as adverse prognostic factor (HR 2.5), linking ongoing drinking with worse HE outcomes and higher mortality.
- Rifaximin added to lactulose reduced HE recurrence (HR 0.42); lactulose superior to placebo; polyethylene glycol showed faster acute improvement, evidence limited.
Arq Gastroenterol. 2026 Oct 30;63:e26066. doi: 10.1590/S0004-2803.24612026-066. eCollection 2026.
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.
PMID:42987036 | PMC:PMC13722408 | DOI:10.1590/S0004-2803.24612026-066
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