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Diagnosing Hepatic Encephalopathy

Learn if you or someone you love is at risk of getting HE, what triggers this complication and how it’s exhibited.

HE encompasses a range of mental and physical symptoms depending on the severity of the condition. Symptoms may begin slowly and gradually get worse, or they may occur suddenly and be severe from the start. In this section you’ll learn about the stages of HE and how this condition is diagnosed.

Here are some facts about who gets HE:

  • Most often seen in people with cirrhosis
  • Can occur in people of any age who have acute or chronic liver disease
  • Affects men and women equally
  • More likely to occur in people that have had a TIPS procedure or surgical shunts

About 7 out of 10 people with cirrhosis develop minimal HE (Grade 0); the exact number isn’t known because symptoms are subtle at this stage, making it difficult to diagnose. What is known is that you are at least three times more likely to progress from minimal to obvious, or overt, symptoms of HE if it’s not diagnosed early. So communicate with your doctor right away if you suspect you may have HE so that treatment can be started as soon as possible.

People with chronic liver disease are at greater risk of developing a more chronic form of the disorder where symptoms get worse or continue to come back, known as “HE recurrence.” It isn’t known why some people experience HE recurrences and others do not, but there are several possible triggers.

HE encompasses a range of symptoms depending on the severity of the condition, so symptoms can vary widely from one person to another. Symptoms may begin slowly and gradually get worse, or they may occur suddenly and be severe from the start.

Mild to moderate symptoms of HE may include the following mental and physical changes:

  • Mental
    • Mild confusion
    • Short attention span
    • Forgetfulness
    • Mood swings
    • Personality changes
    • Inappropriate behavior
    • Difficulty doing basic math
  • Physical
    • Change in sleep patterns (like sleeping during the day and staying up at night)
    • Difficulty writing or doing other small hand movements
    • Breath that smells musty or sweet
    • Slurred speech

More severe symptoms of HE may include these mental and physical changes:

  • Mental
    • Marked confusion
    • Severe anxiety or fearfulness
    • Disorientation regarding time and place
    • Inability to perform mental tasks such as doing basic math
  • Physical
    • Extreme sleepiness
    • Slowed or sluggish movement
    • Shaking of hands or arms (called “flapping”)
    • Jumbled, slurred speech that can’t be understood

In the most severe form of HE, people can become unresponsive, unconscious and enter a coma.

The severity of HE is judged according to your symptoms. The most commonly used staging scale of Hepatic Encephalopathy is called the West Haven Grading System:

  • Grade 0: Minimal HE
    This stage is very hard to detect as changes in your memory, concentration and intellectual functioning are so minimal that they may not be outwardly noticeable, even to you. Coordination can be affected and although subtle, may impact your ability to drive a car. If you recently had poorer performance at work or have committed a number of traffic violations while driving, it would be worth bringing this to the attention of your healthcare provider. You may be referred for special testing, called neuropsychiatric testing, to evaluate your thinking abilities by doing a number of specifically designed tasks with a trained examiner. If your test reveals some deficits, your healthcare provider will likely schedule frequent follow-up visits to closely follow your condition. There are currently no medications approved by the FDA to treat minimal HE.
  • Grade 1: Mild HE
    You may have a short attention span, notice mood changes like depression or irritability, and have sleep problems.
  • Grade 2: Moderate HE
    You may keep forgetting things, have no energy and exhibit inappropriate behavior. Your speech may be slurred and you can have trouble doing mental tasks such as basic math. Your hands might shake and you can have difficulty writing.
  • Grade 3: Severe HE
    You may be confused as to where you are or what day it is and be extremely sleepy, but can still be woken up. You may be unable to do basic mental tasks, feel extremely anxious and act strangely.
  • Grade 4: Coma
    The last stage of HE is when the person becomes unconscious and slips into a coma.

An episode of HE may be triggered by any of the following things:

  • Infections
  • Constipation
  • Dehydration: This happens when you don’t get enough water or other fluids.
  • Bleeding from your intestines, stomach or esophagus (the tube that connects your mouth to your stomach). This is referred to as gastrointestinal, or GI, bleeding.
  • Medications that affect your nervous system, such as sleeping pills, antidepressants or tranquilizers.
  • Kidney problems
  • An alcohol binge
  • Surgery
  • Having a portosystemic shunt: This is a tube that’s placed in your liver, sometimes called a TIPS, or a surgical procedure to reroute blood flow and relieve high blood pressure in the veins in and around your liver, a condition called portal hypertension.

There is no specific test used to diagnose HE. A Hepatic Encephalopathy diagnosis is based on a combination of three things:

  • Your medical history;
  • Your symptoms;
  • A thorough clinical exam by your healthcare provider.

Blood tests can identify abnormalities associated with liver and kidney dysfunction, infections, bleeding and other conditions that may contribute to HE. However, these tests are not specific to HE and simply aid in making the Hepatic Encephalopathy diagnosis which is based on your history and symptoms. Ammonia levels are sometimes used, but these values alone cannot diagnose HE.

Because many of the symptoms of HE also occur in people with other types of brain disease or damage – such as stroke, brain tumor, or bleeding inside the skull – your healthcare provider may order specialized pictures of your brain to rule these out.

These imaging tests, as they’re called, are obtained by using various types of equipment and will likely include MRI (magnetic resonance imaging) and CT (computerized tomography) scans. In addition, your doctor may order an EEG (electroencephalogram), a test that measures the electrical activity of your brain, to look for brain wave changes associated with HE.

Since there is no specific “HE test” the diagnosis of HE is often referred to as a diagnosis of exclusion. This means that it’s important for your doctor to exclude – or rule out – other possible causes for your symptoms in order to correctly diagnose you with HE.


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