Hepatic encephalopathy

Hepatic encephalopathy (HE) is a neurocognitive disorder associated with both acute and chronic liver injury. It manifests as a wide spectrum of neuropsychological abnormalities ranging from subtle impairments in executive higher functions through to coma. In acute liver failure, the central role of ammonia in the development of brain oedema remains undisputed. However, the gut microbiome and the presence of systemic inflammation or the development of infection have become increasingly recognized as drivers of the development of HE in cirrhosis. The development of HE is often unpredictable and its management, particularly in ward environments, remains challenging. Patients frequently require augmented levels of care in a high-dependency or intensive care area. The probability of maintaining transplant-free survival after a first episode of HE at 3 years is only 23% so referral for liver transplantation should be considered early. This review covers the practical aspects of managing HE and provides an up-to-date overview of the evidence base in this area, focusing predominantly on the management of HE in chronic liver disease.