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 subclinical alterations to coma. In acute liver failure, the central role of ammonia in the development of brain oedema remains undisputed. However, the roles of inflammation, infection and the gut microbiota have become increasingly recognized as factors modulating the cerebral impact of hyperammonaemia in cirrhosis. The development of HE is often unpredictable and its management, particularly in a ward environment, remains challenging. Patients frequently require augmented levels of care in a high-dependency or intensive care arena. The probability of maintaining a transplant-free survival after a first episode of HE at 3 years is only 23% and therefore 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, focussing predominantly on the management of the condition in chronic liver disease.