Hepatic encephalopathy is a syndrome of neuropsychiatric symptoms and signs, including coma, observed in patients with cirrhosis. It is probably due to the accumulation of toxins in the blood.

Clinical features

  • Grade 0: Subclinical – personaity changes, construction apraxia (inability or difficulty to build, assemble, or draw objects)
  • Grade I: Confusion, flap tremor
  • Grade II: Drowsy
  • Grade III: Stuporous
  • Grade IV: Coma
  • Encephalopathy may be aggravated by surgery, parencentsis, excessive diuretics, sedatives, and opioid
  • Intracranial hypertension and sepsis are the main causes of death


Management involves addressing the pathophysiological mechanisms related to brain, gut and liver

  • Identify and correct precipitating factors including renal impairment, gastrointestinal
    bleeding, infections, and electrolyte disturbances
  • Empty the gut
    • Give oral lactulose 15-30 mL every 8 hours until the condition resolves (aim at 2-3 soft stools/day)
    • Lactulose can be administered through a nasogastric tube (grade 1 and 2) or as an enema in
      patients with acute HE (grade 3 and 4)
  • Refer to a specialist

If referral delays

  • Give an antibiotic with a local action on the gut: oral metronidazole 400–800 mg every 8 hours
    for 5 days
  • Or oral paromomycin 1000 mg every 6 hours for 5 days