Hepatic Encephalopathy — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] West Haven grade
   West Haven grade (overt HE = grade 2–4)? (On a background of cirrhosis/portosystemic shunting. West Haven: grade 1 (reduced attention/calculation, mild asterixis); grade 2 (lethargy/apathy, disorientation, obvious asterixis, slurred speech); grade 3 (somnolent to semi-stuporous but rousable, severe disorientation, abnormal behavior); grade 4 (coma). Overt HE = grade 2–4. Ammonia is not used to guide treatment; a normal ammonia should prompt considering another diagnosis. Use GCS in grade 3–4, watch for aspiration.)
   • Grade 3–4 (severe) → Grade 3–4 → airway protection
   • Grade 1–2 (mild–moderate) → Grade 1–2
2. [End] Grade 1–2
   1) First find and treat the precipitant (infection especially SBP, GI bleeding, constipation, dehydration, electrolyte disturbance [hypokalemia/hyponatremia], sedatives, worsening renal function). 2) Lactulose first-line, titrated to 2–3 soft stools/day (PEG if not tolerated); add rifaximin for recurrence or worsening. 3) Do not restrict protein (1.2–1.5 g/kg/day), nutritional support. Reassess; if no improvement at 48–72 h, re-evaluate the diagnosis.
3. [End] Grade 3–4 → airway protection
   Somnolent to comatose: admit/ICU, protect the airway to prevent aspiration (triage with GCS); aggressively find and treat the precipitant (infection/bleeding/electrolytes/renal failure/sedatives); lactulose (oral or retention enema 300 mL + 700 mL water, q4–6h) + rifaximin; correct electrolytes, nutritional support; avoid sedatives. Re-evaluate the diagnosis if no improvement at 48–72 h.

Source guidelines & references

• ACG 2026 Clinical Guideline on hepatic encephalopathy; West Haven grading

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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