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  • Hepatic encephalopathy (HE) defines a spectrum of neurologic and neuropsychiatric irregularities that develop in a patient with liver disease, after other causes are ruled out. It can range from minimal hepatic encephalopathy (MHE) and covert hepatic encephalopathy (CHE) to overt hepatic encephalopathy (OHE) with significant symptoms and impairment (Fig. 14-1).

  • It was described by Hippocrates (460–371 BC) when he stated that the “yellow bile causes the patient to thrash around.”

  • Although it is considered a completely reversible syndrome, some research establishes an accumulative effect in cognition deficits of affected patients over time.


  • Based on the underlying cause, HE can be classified as type A, HE associated with acute liver failure; type B. HE with a portosystemic bypass and no intrinsic liver disease; and type C, HE associated with cirrhosis or portal hypertension (Table 14-1).

  • The most commonly used classification system is the West Haven Criteria (WHC) classification, which is based on clinical findings (Table 14-2).

  • MHE is described as subtle neuropsychological alterations only identifiable by psychometric tests and with no clinical manifestations. MHE occurs before WHC grade 1.

  • HE can be also classified as episodic, recurrent, or persistent based on its time course (Fig. 14-2).

  • According to the identification of triggers, HE can be spontaneous or precipitated. In type C HE, almost all the time a trigger can be identified (Table 14-3).

  • In summary, if we combine all classifications, we will have a complete picture of the HE in any particular patient (Table 14-4).


HE time course classification.

TABLE 14-1HE Classified by Underlying Cause
TABLE 14-2West Haven Criteria for Hepatic Encephalopathy
TABLE 14-3Triggers of HE

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