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Hepatic Encephalopathy, Emergency Medicine

Sidney James and Matthew N. Graber Reviewed 06/2017



Hepatic encephalopathy (HE) is characterized by changes in behavior, consciousness, and motor disturbances, associated with hepatic insufficiency and the accumulation of substances n...


Signs and Symptoms

  • Type A: Rapidly progresses to seizures, decerebrate rigidity, coma, and frequently death from cerebral edema.

  • Type B and C are chronic conditions that may manifest as minima...


Initial Stabilization/Therapy

  • Oxygen

  • Airway protection:

    • Patients with grade 3 or 4 HE may require intubation for airway protection. Propofol is the preferred agent for sedation.

  • Cardiac monitor

  • F...



Admission Criteria

  • HE grade 2, 3, or 4 or inadequate social support

  • Type A HE (any grade) and type B or C (grade 2 or above) should be admitted to the ICU with urgent GI consult

  • Asso...

Pearls and Pitfalls

  • Consider rifaximin for lactulose-resistant HE

  • Hypoglycemia is common in HE patients.

  • Avoid sedatives and narcotics if possible in HE patients. If necessary, use medications not metab...

Additional Reading

  • Eroglu  Y, Byrne  WJ. Hepatic encephalopathy. Emerg Med Clin North Am.  2009;27(3):401–414.

  • Khungar  V, Poordad  F. Hepatic Encephalopathy. Clin Liv Dis.  2012;16:301–320.

  • R...



  • 070.6 Unspecified viral hepatitis with hepatic coma

  • 070.9 Unspecified viral hepatitis without mention of hepatic coma

  • 572.2 Hepatic encephalopathy


  • B19.0 Unspecified viral hepatitis with he...

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