Hepatic encephalopathy

Last reviewed: 2 Nov 2022
Last updated: 29 Sep 2022

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • mood disturbances
  • sleep disturbances
  • motor disturbances
  • advanced neurological deficits
More key diagnostic factors

Other diagnostic factors

  • asterixis
  • palmar erythema
  • spider angiomata
  • peripheral oedema
  • jaundice
  • hepatomegaly
  • ascites
Other diagnostic factors

Risk factors

  • hypovolaemia
  • gastrointestinal bleeding
  • constipation
  • excessive protein intake
  • hypokalaemia
  • hyponatraemia
  • metabolic alkalosis
  • hypoxia
  • sedative use
  • opioid use
  • diuretic overdose
  • hypoglycaemia
  • infection
  • hepatic or portal vein thrombosis
  • portacaval shunt
  • renal impairment
More risk factors

Diagnostic investigations

1st investigations to order

  • liver function tests
  • serum glucose
  • coagulation profile
  • serum electrolytes
  • urea and creatinine
  • arterial or venous blood gas
  • FBC
  • inflammatory markers (e.g., CRP)
  • thyroid-stimulating hormone
  • blood alcohol level
  • blood ammonia level
  • urine culture
  • blood culture
  • urine toxin screen
  • ultrasonography
  • head CT or MRI scan
More 1st investigations to order

Investigations to consider

  • EEG
  • lumbar puncture
  • abdominal paracentesis
More investigations to consider

Treatment algorithm

ACUTE

all patients

ONGOING

previous/recurrent episode

Contributors

Authors

Jasmohan S. Bajaj, MD, FAASLD, FACG, AGAF, FRCP (London), MS

Professor of Medicine

Department of Internal Medicine

Division of Gastroenterology, Hepatology and Nutrition

Virginia Commonwealth University and Central Virginia Veterans Healthcare System

Richmond

VA

Disclosures

JB’s institution has received funding for research from Valeant Mallinckrodt and Grifols. JB has been on advisory boards for Maerz and Norgine.

Acknowledgements

Dr Jasmohan Bajaj would like to gratefully acknowledge Dr Emily Speelmon, Dr Robert Hyzy, and Dr Meilan Han, previous contributors to this topic.

Disclosures

ES, RH, and MH declare that they have no competing interests.

Peer reviewers

Sammy Saab, MD, MPH, AGAF

Professor of Medicine

Department of Internal Medicine and Surgery

David Geffen School of Medicine

UCLA

Los Angeles

CA

Disclosures

SS is a member of the speaker bureau and advisory board for Salix.

Jorge A. Marrero, MD

Assistant Professor of Medicine

Division of Gastroenterology

University of Michigan

Ann Arbor

MI

Disclosures

JAM declares that he has no competing interests.

  • Differentials

    • Brain tumours
    • Subdural haematoma
    • Acute stroke
    More Differentials
  • Guidelines

    • Clinical practice guidelines on the management of hepatic encephalopathy
    • Acute-on-chronic liver failure clinical guidelines
    More Guidelines
  • Calculators

    Child Pugh classification for severity of liver disease (SI units)

    More Calculators
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