Hepatic encephalopathy

(Redirected from Hepatic Encephalopathy)


  • Diagnosis of exclusion
  • Due to accumulation of nitrogenous waste products normally metabolized by the liver
  • Increased metabolism of ammonia to glutamine in CNS
  • Spectrum of illness ranges from chronic fatigue to acute lethargy


Clinical Features

Jaundice of the skin
Spider angioma
Ascites secondary to cirrhosis.


  • Stage I - General apathy
  • Stage II - Lethargy, drowsiness, variable orientation, asterixis
  • Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
  • Stage IV - Coma

Differential Diagnosis




  • Full neuro exam including asterixis
  • Elevated ammonia level. Ammonia is not predictive of severity of disease.
  • History of any new medications or toxin ingestion
  • Focus exam on looking for signs of GI bleed or hypovolemia


  • Lactulose 20g PO or (300mL in 700cc H2O retention enema x30min)
    • In colon degrades into lactic acid: acidic environment traps ammonia
    • Also inhibits ammonia production in gut wall
  • Rifaximin is second line.
  • Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.


  • Discharge stage I if good resources.
  • Stage II will need admission unless known encephalopathy and who is otherwise well.
  • Stage III and IV admission +/- ICU or obs bed.

Patient Information

Hepatic Encephalopathy (Medline Plus)

See Also