Last reviewed: July 2020
Last updated: April  2020



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
  • hypoglycemia
  • infection
  • hepatic or portal vein thrombosis
  • portacaval shunt
  • renal impairment

Diagnostic investigations

1st investigations to order

  • liver tests
  • serum glucose
  • coagulation profile
  • serum electrolytes
  • BUN and creatinine
  • arterial or venous blood gas
  • CBC
  • urine culture
  • blood culture
  • urine toxin screen
  • ultrasonography
  • head CT scan
More 1st investigations to order

Investigations to consider

  • EEG
  • ammonia level
  • lumbar puncture
  • abdominal paracentesis
More investigations to consider

Treatment algorithm


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.

Peer reviewersVIEW ALL

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.

Assistant Professor of Medicine

Division of Gastroenterology

University of Michigan

Ann Arbor



JAM declares that he has no competing interests.

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