Hepatic encephalopathy
Formal Definition
A spectrum of neuropsychiatric abnormalities (confusion, asterixis, stupor, coma) in patients with liver failure or portosystemic shunting, caused primarily by accumulation of ammonia and other gut-derived toxins; graded I–IV by West Haven criteria.
How It's Used on the Ward
"HE" or "encephalopathic" — one of the most common complications of cirrhosis on the hepatology service; ammonia level + precipitant search are the immediate workup.
Example
""Patient with known cirrhosis, admitted confused and not making sense. Ammonia is 142. Looking for precipitants: GI bleed (guaiac positive), constipation, new infection, held lactulose. Starting lactulose 30mL q1–2h until three bowel movements per day, rifaximin already on board.""
Clinical Context
Precipitants of HE (mnemonic TIPS): T = toxins/meds, I = infection (SBP is #1 — always tap the ascites), P = protein load (GI bleed is a huge protein load), S = shunt (TIPS procedure itself). Treatment: lactulose (traps ammonia in gut as NH4+, causes diarrhea — goal 3–4 loose stools/day) + rifaximin (non-absorbed antibiotic). Do NOT give sedatives (benzodiazepines) — dramatically worsens encephalopathy. Ammonia level does not reliably correlate with encephalopathy grade.