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Hepatic encephalopathy

Last reviewed: 9 Sep 2024
Last updated: 06 Aug 2024

Summary

Definition

History and exam

Key diagnostic factors

  • mood disturbances
  • sleep disturbances
  • motor disturbances
  • advanced neurologic deficits
Full details

Other diagnostic factors

  • asterixis
  • spider angiomata
  • palmar erythema
  • peripheral edema
  • jaundice
  • hepatomegaly
  • ascites
Full details

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
Full details

Diagnostic tests

1st tests 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
Full details

Tests to consider

  • EEG
  • lumbar puncture
  • abdominal paracentesis
Full details

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 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.

  • Differentials

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    • Subdural hematoma
    • Acute stroke
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  • Guidelines

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

    Child Pugh classification for severity of liver disease

    MELDNa scores (for liver transplantation listing purposes, not appropriate for patients under age 12 years)

    More Calculators
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