Skip to content

Hepatic Encephalopathy (HE)

  • Ahmad Yanis

Classifications of HE:

  • Type A: in patients with acute liver failure
  • Type B: in patients with portosystemic shunt without significant liver disease
  • Type C: in patients with cirrhosis
  • Covert HE: minor or no signs/symptoms but abnormalities on neuropsychological and/or neurophysiological tests
  • Overt HE: Clinically appreciable change In mental status (e.g., AxOx2 or asterixis) recurrent (≥ 2 bouts) within 6 months
  • persistent if the patient does not return to their baseline performance between bouts.


  • Asterixis: inability to maintain stable posture; many ways to assess
    • Check for clonus
    • Have pt “hold out hands like you are stopping traffic” (if following commands)
    • Shine light in pupil (look up video of hippus)
0 1 2 3
Grade Behavior change Asterixis Cerebral Edema in Acute Liver Failure:
I Mild confusion, changes in behavior, increased sleep No Asterixis No cerebral edema
II Moderate confusion, lethargic Asterixis Rare cerebral edema
III Marked confusion, arousable but falls asleep, incoherent speech Asterixis ~30% cerebral edema
IV Coma No Asterixis ~75% cerebral edema
  • Identify precipitants

    • Infection (rule out SBP in addition to CXR, BCx, UA/Cx),
    • Medication non-adherence (lactulose)
    • GI bleed (perform rectal exam and observe Hgb trend)
    • Over-diuresis resulting in dehydration, electrolyte abnormalities (especially hypoK)
    • Sedatives/benzo/opiate administration (UDS)
    • Brain imaging does not provide any diagnostic value for HE but may be utilized if diagnostic uncertainty exists
  • Increase ammonia (NH3) levels do not add any diagnostic, staging, or prognostic value in patients with CLD. A normal ammonia level, however, calls for diagnostic re-evaluation

  • Arterial NH3 is used in acute liver failure for prognostication (not for management)


  • Always determine precipitant and treat underlying condition

  • Lactulose 30mL TID initially titrated to 2-3 BMs/D as secondary prophylaxis after the management of first episode of overt HE.

    • Titrate dose to at least 4 BMs daily, avoid excessive stool output which may exacerbate HE due to dehydration and electrolyte abnormalities
    • Consider lactulose enemas vs DHT placement if pt unable to tolerate PO
      • DHT are not contraindicated in patients with esophageal varices, but should be avoided in patients with recent hemorrhage or banding
    • Add Rifaximin after the second episode of HE, or if failure to respond to lactulose
      • Frequently requires prior auth for OP approval and is expensive
  • Lactulose is generally continued indefinitely after first episode of HE, though discontinuation can be considered on an individual basis if predisposing factors (recurrent infection, EVH, EtOH use) have resolved, improvement in liver function, and improvement in nutritional status

  • For patients with chronic diarrhea off lactulose, consider adding BCAA (0.25 gm/kg/d)