is a reversible neuropsychiatric complication that is a feature of both chronic and acute liver disease.
- Manifestations range from subtle, subclinical abnormalities that can only be discerned by formal psychometric tests (minimal HE) to clearly evident neurologic and behavioral derangements that are easily diagnosed at the bedside (overt HE).
- Although HE can appear as the result of portal systemic shunting without intrinsic liver disease, the onset of HE is generally associated with advanced hepatocellular disease, and its appearance is often accompanied by other phenomena of end-stage liver disease such as ascites, hypoalbuminemia, hyperbilirubinemia, and elevations in INR.
- The initial step in evaluating a patient with liver disease who presents with encephalopathy is to rule out causes other than HE (metabolic encephalopathies such as uremia, sepsis, glucose, electrolyte abnormalities, endocrinopathies).
- Cirrhotic patients are exquisitely sensitive to sedative medications and have impaired hepatic (and often renal) metabolism; careful search for possible drug-related encephalopathy should be undertaken.
- After other potential causes have been eliminated, the next step should be a systematic search for an underlying cause or precipitating factor.