Hepatic Encephalopathy

Hepatic encephalopathy is a syndrome. This is a set of symptoms that occur together. It is seen mostly in patients with damage to the liver known as cirrhosis. This is where normal liver tissue has been replaced by scar tissue.

Symptoms of the syndrome include:

  • Changes in personality.

  • Mental impairment.

  • A depressed level of consciousness.

These changes occur because toxins build up in the bloodstream. The build up occurs because the scarred liver cannot rid toxins from the body. The most important of these toxins is ammonia. Toxins can cause abnormal behavior and confusion. Toxins in the blood stream can impair your ability to take care of yourself or others. Some people become very sleepy and cannot be woken easily. In severe cases, the patient lapses into a coma.


There are many things that can cause liver damage that can lead to buildup of toxins. These include:

  • Diseases that cause cirrhosis of the liver.

  • Long-term alcohol use with progressive liver damage.

  • Hepatitis B or C with ongoing infection and liver damage.

  • Patients without cirrhosis who have undergone shunt surgery.

  • Kidney failure.

  • Bleeding in the stomach or intestines.

  • Infection.

  • Constipation.

  • Medications that act upon the central nervous system.

  • Diuretic therapy.

  • Excessive dietary protein.


Symptoms of this syndrome are categorized or "staged" based on severity.

  • Stage 0. Minimal hepatic encephalopathy. No detectable changes in personality or behavior. Minimal changes in memory, concentration, mental function, and physical ability.

  • Stage 1. Some lack of awareness. Shortened attention span. Problems with addition or subtraction. Possible problems with sleeping or a reversal of the normal sleep pattern. Euphoria, depression, or irritability may be present. Mild confusion. Slowing of mental ability. Tremors may be detected.

  • Stage 2. Lethargy or apathy. Disoriented. Strange behavior. Slurred speech. Obvious tremors. Drowsiness, unable to perform mental tasks. Personality changes, and confusion about time.

  • Stage 3. Very sleepy but can be aroused. Unable to perform mental tasks, cannot keep track of time and place, marked confusion, amnesia, occasional fits of rage, speech cannot be understood.

  • Stage 4. Coma with or without response to painful stimuli.


In mild cases, a careful history and physical exam may lead your caregiver to consider possible mild hepatic encephalopathy as the cause of symptoms. The diagnosis is clearer in more severe cases. An elevated blood ammonia level is the classic blood test abnormality in patients with this syndrome. Other tests can be helpful to rule out other diseases.


  • Medications are often used to lower the ammonia level in the blood. This usually leads to improvement.

  • Diets containing vegetable proteins are better than diets rich in animal protein, especially proteins derived from red meats. Eating well-cooked chicken and fish in addition to vegetable protein should be discussed with your caregiver. Malnourished patients are encouraged to add liquid nutritional supplements to their diet.

  • Antibiotics are sometimes used to try to lessen the volume of bacteria in the intestines that produce ammonia.

  • Moderate to severe cases of this syndrome usually require a hospital stay and medicine that is given directly into a vein (intravenously).


The goal at home is to avoid things that can make the condition worse and lead to a buildup of ammonia in the blood.

  • Eat a well balanced diet. Your caregiver can help you with suggestions on this.

  • Talk to your caregiver before taking vitamin supplements. Large doses of vitamins and minerals, especially vitamin A, iron, or copper, can worsen liver damage.

  • A low salt diet, water restriction, or diuretic medicine may be needed to reduce fluid retention.

  • Avoid alcohol and acetaminophen as well as any over-the-counter medications that contain acetaminophen (check labels). Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver.

  • Avoid drugs that are toxic to the liver. Review your medications (both prescription and non-prescription) with your caregiver to make sure those you are taking will not be harmful.

  • Blood tests may be needed. Follow your caregiver's advice regarding the timing of these.

  • With this condition you play a critical role in maintaining your own good health. The failure to follow your caregiver's advice and these instructions may result in permanent disability or death.


  • You have increasing fatigue or weakness.

  • You develop increasing swelling of the abdomen, hands, feet, legs or face.

  • You develop loss of appetite.

  • You are feeling sick to your stomach (nausea) and vomiting.

  • You develop jaundice. This is a yellow discoloration of the skin.

  • You develop worsening problems with concentration, confusion, and/or problems with sleep.


  • You vomit bright red blood or a coffee ground-looking material.

  • You have blood in your stools. Or the stools turn black and tarry.

  • You have a fever.

  • You develop easy bruising or bleeding.

  • You have a return of slurred speech, change in behavior, or confusion.


  • Understand these instructions.

  • Will watch your condition.

  • Will get help right away if you are not doing well or get worse.