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 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
Tests 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.
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
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- Acute-on-chronic liver failure clinical guidelines
- Clinical practice guidelines on the management of hepatic encephalopathy
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