Last reviewed: 23 Dec 2021
Last updated: 07 Apr 2020



History and exam

Key diagnostic factors

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

Other diagnostic factors

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

Risk factors

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

Diagnostic investigations

1st investigations to order

  • liver tests
  • serum glucose
  • coagulation profile
  • serum electrolytes
  • urea and creatinine
  • arterial or venous blood gas
  • FBC
  • urine culture
  • blood culture
  • urine toxin screen
  • ultrasonography
  • head CT scan

Investigations to consider

  • EEG
  • ammonia level
  • lumbar puncture
  • abdominal paracentesis

Treatment algorithm



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




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


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


ES, MH, and RH 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


Los Angeles



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



JAM declares that he has no competing interests.

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