Intended for healthcare professionals

Clinical Review

Hepatic encephalopathy due to liver cirrhosis

BMJ 2015; 351 doi: (Published 11 August 2015) Cite this as: BMJ 2015;351:h4187
  1. Mark A Ellul, academic clinical fellow1,
  2. Santosh A Gholkar, general practitioner, clinical lead (North Manchester Clinical Commissioning Group)2,
  3. Timothy J Cross, consultant hepatologist3
  1. 1Institute of Infection and Global Health, University of Liverpool, Liverpool L69 7BE, UK
  2. 2City Health Centre, Manchester M1 1PL, UK
  3. 3Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
  1. Correspondence to: TJ Cross tim.cross{at}

The bottom line

  • Hepatic encephalopathy is a sign of poor prognosis and correlates with mortality in both in patients with acute liver failure and those with cirrhosis associated with end stage liver disease

  • Patients without overt hepatic encephalopathy can have subtle cognitive deficits affecting quality of life that may be responsive to treatment

  • Hepatic encephalopathy is a clinical diagnosis that can be assisted by neuropsychology and neurophysiology

  • Evidence based treatments, such as lactulose and rifaximin, influence both length and quality of life

Overt hepatic encephalopathy affects approximately 20% of patients with liver cirrhosis each year.1 It is a pathognomonic feature of liver failure and a common cause of admission to emergency departments. It affects the quality of life of both patient and relatives2 and signifies a poor prognostic indicator for patients with cirrhosis, with a survival of only 23% at three years from onset.3 Treatments aimed at interrupting the pathogenesis of hepatic encephalopathy are known to reduce frequency of hospital admissions and improve survival.4

Studies suggest that the prevalence of chronic liver disease in the United Kingdom is increasing, in part owing to the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), alcohol related liver disease, and hepatitis C.5 6 Clinicians therefore need to be able to recognise signs and symptoms of hepatic encephalopathy in patients who might not have a diagnosis of chronic liver disease.

This review aims to highlight the importance of recognising hepatic encephalopathy in chronic liver failure and outlines a practical and evidence based approach to its management, based on the framework of recent guidelines from the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD).4 Hepatic encephalopathy in acute liver failure is managed differently, and will not be addressed.

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