Last reviewed:September 2019
Last updated:December  2017



History and exam

Key diagnostic factors

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

Other diagnostic factors

  • palmar erythema
  • spider angiomata
  • peripheral oedema
  • jaundice
  • hepatomegaly
  • ascites
  • hemiplegia

Risk factors

  • cirrhosis
  • hypovolaemia
  • gastrointestinal bleeding
  • hypokalaemia
  • metabolic alkalosis
  • hypoxia
  • sedative use
  • hypoglycaemia
  • infection
  • hepatic or portal vein thrombosis
  • acute hepatic failure
  • portacaval shunt

Diagnostic investigations

1st investigations to order

  • LFTs
  • serum glucose
  • coagulation profile
  • urine culture
  • blood culture
  • urine toxin screen
  • ultrasonography
  • psychometric tests
  • head CT scan
Full details

Investigations to consider

  • EEG
  • ammonia level
  • lumbar puncture
  • abdominal paracentesis
Full details

Treatment algorithm


Affiliate Assistant Professor, Pulmonary and Critical Care Medicine

Department of Medicine

Oregon Health and Science University School of Medicine




ES declares that she has no competing interests.

Dr Emily Speelmon would like to gratefully acknowledge Dr Robert Hyzy and Dr Meilan Han, previous contributors to this monograph. MH and RH declare that they have no competing interests.

Peer reviewersVIEW ALL

Assistant Professor of Medicine

Division of Gastroenterology

University of Michigan

Ann Arbor



JAM declares that he has no competing interests.

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