Hepatic encephalopathy
Summary
Definition
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
- opioid use
- diuretic overdose
- hypoglycaemia
- 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
- 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
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 research support from Bausch, Grifols, Cosmo, and Sequana.
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.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug;60(2):715-35.Full text Abstract
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of hepatic encephalopathy. J Hepatol. 2022 Sep;77(3):807-24.Full text Abstract
Bajaj JS, O'Leary JG, Lai JC, et al. Acute-on-chronic liver failure clinical guidelines. Am J Gastroenterol. 2022 Feb 1;117(2):225-52.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Brain tumours
- Subdural haematoma
- Acute stroke
More DifferentialsGuidelines
- Clinical practice guidelines on the management of hepatic encephalopathy
- Acute-on-chronic liver failure clinical guidelines
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MELDNa scores (for liver transplantation listing purposes, not appropriate for patients under age 12 years) (SI units)
Child Pugh classification for severity of liver disease (SI units)
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