Summary
Definition
History and exam
Key diagnostic factors
- mood disturbances
- sleep disturbances
- motor disturbances
- advanced neurologic deficits
Other diagnostic factors
- asterixis
- spider angiomata
- palmar erythema
- peripheral edema
- jaundice
- hepatomegaly
- ascites
Risk factors
- hypovolemia
- gastrointestinal bleeding
- constipation
- excessive protein intake
- hypokalemia
- hyponatremia
- metabolic alkalosis
- hypoxia
- sedative use
- opioid use
- diuretic overdose
- hypoglycemia
- infection
- hepatic or portal vein thrombosis
- portacaval shunt
- renal impairment
Diagnostic investigations
1st investigations to order
- liver function tests
- serum glucose
- coagulation profile
- serum electrolytes
- BUN and creatinine
- arterial or venous blood gas
- CBC
- 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
Investigations to consider
- EEG
- lumbar puncture
- abdominal paracentesis
Treatment algorithm
all patients
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 tumors
- Subdural hematoma
- Acute stroke
More DifferentialsGuidelines
- Clinical practice guidelines on the management of hepatic encephalopathy
- Acute-on-chronic liver failure clinical guidelines
More GuidelinesCalculators
Child Pugh classification for severity of liver disease
MELDNa scores (for liver transplantation listing purposes, not appropriate for patients under age 12 years)
More CalculatorsLog in or subscribe to access all of BMJ Best Practice
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