Liver failure

Hepatic encephalopathy

Reviewed Nov 2026·2 references
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Grade HE, find and treat precipitants, give lactulose (or PEG), add rifaximin, protect the airway and keep feeding.

Definition
HE is brain dysfunction due to liver insufficiency and/or portosystemic shunting. West Haven grades: I (trivial lack of awareness, short attention), II (lethargy, disorientation, asterixis), III (somnolence, confusion, responsive to stimuli), IV (coma).

At the bedside

  1. 1

    Exclude other causes

    Hypoglycaemia, sepsis, hyponatraemia, intracranial bleed (CT if focal signs or fall), alcohol withdrawal, Wernicke, drugs. A normal ammonia should prompt a search for another diagnosis.

  2. 2

    Treat precipitants

    Infection, GI bleeding, constipation, dehydration/over-diuresis, hypokalaemia, sedatives/opioids, TIPS, AKI.

  3. 3

    Airway

    Grade III-IV: nurse in HDU/ICU; intubate if unable to protect airway (GCS ≤ 8) or for endoscopy.

  4. 4

    Lactulose

    25-30 mL every 1-2 h until bowel motion, then titrate to 2-3 soft stools/day. Via NG or enema if unable to swallow.

  5. 5

    PEG 3350 alternative

    4 L PEG over 4 h resolved HE faster than lactulose in HELP; consider when lactulose fails (airway risk).

  6. 6

    Rifaximin

    Add 550 mg BD for recurrent HE (secondary prophylaxis with lactulose).

  7. 7

    Nutrition

    Do not restrict protein: 1.2-1.5 g/kg/day, energy 35 kcal/kg/day, late evening snack; enteral feeding if unable to eat.

  8. 8

    Refractory

    Consider LOLA, embolisation of large spontaneous portosystemic shunts, TIPS reduction; transplant evaluation.

Overt HE

Lactulose

Oral/NG
Dose
25-30 mL every 1-2 h until bowel motion, then titrate to 2-3 stools/day

Enema: 300 mL in 700 mL water, retained 30-60 min.

Recurrent HE

Rifaximin

Oral
Dose
550 mg twice daily

Alternative to lactulose

Polyethylene glycol 3350-electrolyte

Oral/NG
Dose
4 L over 4 h

West Haven grades

GradeFeatures
Covert (minimal/I)Abnormal psychometrics; mild inattention, sleep inversion
IILethargy, disorientation to time, inappropriate behaviour, asterixis
IIISomnolent but rousable, gross disorientation, bizarre behaviour
IVComa
Red flag · call your senior now
Focal neurology or head injury in a cirrhotic with confusion: CT head (coagulopathy, falls).
Pitfall
Restricting protein: worsens sarcopenia and outcomes.
Pitfall
Excess lactulose causing dehydration, hypernatraemia and AKI.
Pearl
HE is a clinical diagnosis; ammonia helps mainly by its negative predictive value.

Calculators for this topic

Glasgow Coma Scale

Eye + Verbal + Motor (3-15). Record components, e.g. E3 V4 M5.

References

  1. 1

    European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. J Hepatol 2022;77:807-24.

  2. 2

    Rahimi RS, Singal AG, Cuthbert JA, Rockey DC. Lactulose vs polyethylene glycol 3350-electrolyte solution for treatment of overt hepatic encephalopathy: the HELP randomized clinical trial. JAMA Intern Med 2014;174:1727-33.

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