What are signs of hepatic encephalopathy and when should I get help

I have a close relative with cirrhosis and she has ascites, portal hypertension and abnormal blood results etc.....how will I know if she has hepatic encephalopathy...is there a score system? She can still hold a normal conversation although is quite irritable over little things and is very forgetful about where she puts things and totally forgetful about appointments etc.

Is there an assessment I can do to know if she is deteriorating and also what's the treatment for this other than lactulose.

Many thanks,

Very Concerned

16 Replies

  • The most reliable information about HE is on the British Liver Trust page :-


    My hubby has mild HE symptoms and takes Lactulose and also Rifaximin.


  • As Aryshirek just said, the British Liver Trust website has an excellent pamphlet that explains Hepatic Encephalopathy. You should get anybody who comes into contact with your relative to read it and look at the website for themselves so they can get a better understanding of what is happening. without this knowledge seeing somebody with HE can be bewildering or when its severe quite frightening.

    There is a few simple tests you can do to confirm that HE is begining to take effect.

    One is to get them to hold their arms straight out in front with the hands flexed at right angles upwards at the wrist. After about 30 - 45 seconds The hand may begin to have an uncontrolled flapping motion, this is what your doctor may ask you to do. The movement is known as Asterixis.

    Another easy thing to do is to ask the person to join dots together using a pen, they will find this extremely difficult with HE.

    Finally, ask the person when they are completely well to write a long sentence such as 'The quick brown fox jumped over the lazy dog' Keep that peice of writing so you can compare it later. Then when you think they may be experiencing HE ask them to write the same sentence. They will either find it impossible or you will have great difficulty in reading what they have written.

    Whenever you decide that HE is occuring you should seek medical help immediately as left untreated HE can be very serious.

    On a less serious note, my partner said if I can pronounce 'hepatic encaphalopathy' and say it quickly, I probably didnt have it !

    Which brings me to the important point that the person with HE is mostly not aware its happening. This is why its very important that you and others close to him/her are able to spot the signs.

    Hope this helps


  • Further to my post:

    As I said the person with HE is often completely unaware that there is anything wrong. so be prepared for he or she telling you that you are imagining things and there is nothing wrong with them.

    It can be a good idea for you to discuss this with them when they are completely well. You have to get them to understand that when it happens they have to trust your judgement and agree to accept help / medical support. This way you may lessen the problems that can arise when you may have to get help without their permission or knowledge.

    In my case I often refused to go with an ambulance crew saying I was fine when in fact I wasnt even able to tell them who I was and couldnt stand properly.

    Thankfully they didnt take no for an answer and together with my partner were able to persuade me to go to hospital. Usually A & E was a brief stop before going to a ward where they knew me well.


  • Many thanks...excellent advice. It seems doctors these days don't tell you information until you ask about it!

    Yes there is a lot of forgetfullness, the handwriting has totally deteriorated although she can still hold a normal conversation, and there is definitely asterixis present. This hepatic encephalopathy information will have to come from the doctor because she thinks the diagnosis is coming from me and not the doctor and keeps reminding me "you are not a doctor!". She has a lot of denial about her condition and she'd be very offended if I suggested that mentally she was deteriorating although I will continue to keep a close eye on her.

    Many thanks for your advice!

  • thanks for posting this i was wondering ,,i have all the info to hand but was reluctant to ask ,,as im alone nobody will pickup on HE with me ,,i just tested myself on the basics and i seem ok ,,so ill mention it to the doc and just keep regular Lac going in and all those poisons coming out ,,thanks so much you know what to look for however mild ok get help IMMEDIATELY it can be treated ,,keep the lactulose doses regular dont miss a beat all the best matt ,,

  • Yes; i have been wondering for a long time about HE and someone i know; excellent advice has been given here.

  • Further to the post,

    There is a scoring system called West Haven used to gage severity of HE.HE can be very complexing, your loved one may seem fine at times and moments later have an HE moment, being forgetful, asking the same questions, saying or doing inappropriate things, as it progresses they may start losing coordination and start staggering and/ or fall, and slurring of speech can occur.In my experience if you have to ask the person if their ok, their probably not, as previously noted in the early to mid stages they are completely unaware to the changes in behaviour, so trust your instincts, as you know them best.Hope this helps as HE can be a very tricky condition and be debilitating if left untreated.

    Good luck,


  • Many thanks i will look into this

  • great advice thanks

  • Happy to help, keep an eye on your ammonia (NH3), levels on blood tests these can be an indicator for HE also. Good luck!

  • Hi ,

    It's a fine balance trying to mange Hepatic Encephalopathy but make sure person is hydrated, going to the toilet regularly , and is infection free , earlier on this year my husband suffered from a bad bout , he was hospitalised and I honestly thought he would not recover .....he is like a different person now , his cognitive ability has improved significantly and he is more or less 'back to normal'. As well as taking lactulose and rifaximin twice daily he takes lemon and hot water each morning and is following a vegetarian diet .

    Whilst in hospital my husband deterioated , and it is my opinion , based on personal experiences that general nursing staff do not have the knowledge or the time to support patients who are suffering from HE so basic things like ensuring someone is drinking water or eating is overlooked . There is much to be done to raise awareness of this condition 😊

  • Many thanks for your advice

  • I lost my dad to this horrible condition in the end. The lactalose and rifixamin was not enough to keep the toxins at bay. It began with irratable behaviour and also he was awake all night and would sleep all day. Then it started to become very severe. He would of passed out for days and when he did come around he would have severe confusion. It starts off with stage 1 then goes up to stage 4 which is coma.

  • Sorry to hear about your dad....Yes my relative is very irritable most days !

  • Sorry to hear it is a horrible condition the medication usually keeps it a bay. There is several things that trigger the episodes off unfortunatly my dad was one of the unlucky few inwhich the trigger could not be found and also the meds didnt keep it at bay. He would of took bad episodes once every few days until it eventually hit the final stage. The consultant that treated him in ICU had never seen such high levels of the toxins in any of his patients he treated. I wish your family and relative all the best.

  • Thank-you

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