Endoscopy Sedation Challenges in Patients With Hepatic Encephalopathy: A Focused Review on Propofol and Selective Use of Benzodiazepines

BACKGROUND: Hepatic encephalopathy (HE) presents a significant challenge in gastrointestinal endoscopy sedation due to impaired liver function, which alters drug metabolism and increases the risk of adverse effects. In the absence of clear guidelines and specific biomarkers for diagnosis and assessment of HE, there is insufficient evidence to formulate standardized protocols for management, diagnosis, and sedation during endoscopy. AREAS OF UNCERTAINTY: Rigid protocols for sedation are difficult to implement due to wide variation in patient age, comorbidities, and disease severity, which creates a "gray zone." This leaves decisions heavily reliant on the clinician's preference or experience, patient characteristics, and institutional protocols. This review highlights the strengths and limitations of propofol, midazolam, and remimazolam in efforts to improve sedation strategies for endoscopic procedures in patients with HE. DATA SOURCES: A review was conducted using PubMed and Scopus databases, keeping in view recent publications. Only primary research studies were considered for this review. Inclusion was based on the relevance of patient side effects, sedation outcomes, and safety profiles, with a particular focus on gastrointestinal endoscopy procedures and their implications in HE. RESULTS: Propofol remains preferred in patients with HE, demonstrating manageable cardiovascular and respiratory events without worsening encephalopathy. However, its safety requires careful consideration in this high-risk population. The combination of propofol with adjuncts, such as esketamine, has shown potential in mitigating adverse effects and optimizing sedation protocols in challenging cases. Midazolam, though historically used, is not recommended in HE due to exacerbation of encephalopathy and unfavorable safety profiles. While remimazolam shows promise, no evidence in HE populations precludes definitive conclusions about its efficacy and safety. CONCLUSIONS: Future research should focus on optimizing sedation protocols according to the needs of HE patients, including tools for risk stratification and guidelines considering individual patient profiles. Furthermore, studies must be performed to evaluate remimazolam's outcomes and safety profiles, both as a standalone sedative and in combination with other agents.