What are the key clinical features to consider when diagnosing hepatic encephalopathy in a patient with liver disease?

When diagnosing hepatic encephalopathy (HE) in a patient with liver disease, key clinical features to consider include a spectrum of neuropsychiatric abnormalities ranging from subtle cognitive impairment to profound coma. Early signs often involve changes in attention, concentration, and psychomotor speed, which may manifest as minimal hepatic encephalopathy detectable only through specialized testing. More overt clinical features include altered mental status, confusion, disorientation, asterixis (flapping tremor), sleep disturbances, and personality changes. In advanced stages, patients may present with somnolence, stupor, and eventually coma. It is important to assess for precipitating factors such as infections, gastrointestinal bleeding, electrolyte imbalances, or constipation, which can exacerbate HE. The diagnosis is primarily clinical, supported by the presence of underlying liver disease and exclusion of other causes of encephalopathy. Neuropsychological testing and ammonia levels can aid in diagnosis but are not definitive alone. Recognizing the gradation from minimal to overt HE is crucial for timely management and improving outcomes NICE CG100 Sharma 2009Damulin 2018Dellatore et al. 2020.