Understanding Hepatic Encephalopathy: Patient Knowledge, Adherence, and Barriers to Care in Cirrhosis

INTRODUCTION: Hepatic encephalopathy (HE) is a common and debilitating complication of liver cirrhosis, associated with impaired cognition, reduced quality of life, and frequent hospitalizations. Effective management requires adherence to medications such as lactulose and rifaximin; however, patient understanding and adherence remain suboptimal. This study aimed to assess patient knowledge of HE, medication adherence, and perceived barriers to care among patients with cirrhosis. METHODS: We conducted a cross-sectional study in Bahrain Government Hospitals between January 2022 and December 2024. Adult patients with liver cirrhosis were recruited during outpatient and inpatient encounters. A structured questionnaire assessed knowledge of HE, adherence to treatment, and barriers to care. Adherence and knowledge were assessed using self-reported measures. Factors associated with poor knowledge and non-adherence were analyzed using multivariable logistic regression. RESULTS: A total of 538 patients with cirrhosis were included. The mean age was 56 ± 13 years, and 312 (58.0%) were male. Only 214 patients (39.8%) demonstrated adequate knowledge of HE. While 402 patients (74.7%) were prescribed lactulose, only 279 (52.0%) reported good adherence. Rifaximin was prescribed in 409 patients (76.0%), with higher adherence rates at 74.3% (304 of 409 patients). The most common barriers to adherence included medication side effects (41.2%), lack of understanding of treatment purpose (38.5%), cost concerns (27.3%), and forgetfulness (24.1%). Patients with prior HE episodes had significantly higher knowledge scores (p<0.001). Poor adherence was independently associated with low educational level (OR 2.1, 95% CI 1.3-3.5), inadequate knowledge (OR 2.8, 95% CI 1.7-4.6), and lactulose-related side effects (OR 1.9, 95% CI 1.2-3.1). CONCLUSION: Patient knowledge and adherence to HE therapy remain suboptimal, with significant barriers affecting effective management. Targeted patient education and strategies to improve the tolerability of therapy are essential to reduce HE-related morbidity.