Hepatic encephalopathy

A clinical diagnosis — hunt the precipitant

Ammonia is neurotoxic, GABA/benzodiazepine-like tone rises, glutamatergic transmission falls (; : ). In ALF the same molecule causes cerebral edema — different disease, different card.

Do not screen for cirrhotic HE with a serum ammonia. It does not diagnose or prognosticate in chronic liver disease (). Exclude stroke, seizure, sedatives, hyponatremia, Wernicke, and intracranial catastrophe.
Classify by underlying disease, West Haven grade, time course (episodic, recurrent, persistent), and precipitated vs not.
Asterixis is negative myoclonus. Hands up, or squeeze the examiner’s fingers (milkmaid grip).
Precipitants: infection (tap), dehydration / overdiuresis, GIB, hypokalemia or alkalosis (↑ renal ammonia), renal failure, constipation, hypoxia, benzos/opioids, new HCC, PVT, TIPS.

West Haven	Covert vs overt	Bedside
Grade 1	Covert	Inattention, euphoria or anxiety, sleep inversion, shortened attention span
Grade 2	Overt	Lethargy, disorientation to time, asterixis, personality change, hypoactive DTRs
Grade 3	Overt	Somnolence, still arousable, disoriented to time and place, hyperactive DTRs
Grade 4	Overt	Coma, unresponsive to pain — protect the airway

Lactulose, then rifaximin, feed protein

Lactulose + rifaximin 550 mg BID beats lactulose alone. Add rifaximin after a second episode (secondary prevention) and usually during a hospital admission.
Calories 35–40 kcal/kg/d; protein 1.2–1.5 g/kg/d. Do not chronically protein-restrict a sarcopenic patient. Hold a meal during coma, then feed.
Thiamine if alcohol. Do not overcorrect hyponatremia.

Variceal bleeding on the HE card for a reason

Clinically significant portal hypertension: HVPG ≥10, or varices, or collaterals/ascites, or LSM ≥25 kPa (caution in obesity, MASLD, ALT >3×, PSC) (: ).

No primary prophylaxis without CSPH. LSM 5–9.9 kPa → repeat q3–5 y; 10–14.9 → annually.
CSPH or decompensated with ascites only: NSBB, preferably carvedilol. Decompensated: NSBB first-line; stop for hypotension or recurrent AKI.
NSBB contraindicated: serial EVL q2–8 weeks until eradication, then q1–2 . Skip screening EGD if LSM <20 and platelets >150.
Secondary prophylaxis after a bleed (no TIPS): NSBB + serial EVL q1–4 weeks to obliteration, EGD at 3–6 months then q6–12 months.

Acute bleed: airway, IVs, PPI, octreotide 50 mcg bolus then 50 mcg/h × 2–5 d, ceftriaxone 1 g × 5 d, EGD. Restrictive transfusion Hb 7 (Villanueva, ). Erythromycin pre-EVL. Balloon tamponade as a ; rescue TIPS if banding fails. Early preemptive TIPS (<72 h) if high risk of failure. Do not chase INR/platelets with FFP. Feed once bleeding is controlled. Look for PVT/HCC.
Gastric varices: hard to band — TIPS (especially if esophageal varices too), BRTO, or endoscopic glue/coil.
Portal hypertensive gastropathy: NSBB, octreotide, TIPS.

The INR is not a bleeding score

Cirrhosis lowers clotting factors (except VIII) and anticoagulant proteins (C, S, ATIII), adds dysfibrinogenemia and ↑ tPA fibrinolysis, ± vitamin K deficiency. Early disease tilts toward thrombosis; late disease toward bleeding. Patients are not ‘auto-anticoagulated’ (AGA: ; ).

PT/INR and PTT do not predict bleed or clot. Factor VIII is high (low in DIC). D-dimer is not the DIC extreme.
VTE prophylaxis should not be withheld unless high bleed risk or platelets <50k.
Therapeutic anticoagulation is acceptable unless Child C or high bleed risk; EGD varices first. Apixaban preferred among DOACs; caution in Child B. VKA dosing is confounded by baseline INR; LMWH by low ATIII.
Vitamin K 10 mg × 3 days for the nutritional component. Transfuse Hb <7, platelets <50k for high-risk procedures, cryoprecipitate if fibrinogen <100–120. FFP last — volume raises portal pressure.
Mucocutaneous oozing: aminocaproic acid or TXA.
No FFP to ‘correct’ INR before paracentesis. Platelets >50k for surgery, TIPS, liver biopsy; routine para is often safe >20k. TPO agonists take ~10 days and are not routine ().