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Hepatic Encephalopathy (HE)

Contact the UPMC Center for Liver Diseases

To make an appointment with a hepatologist at the UPMC Center for Liver Diseases, call 412-647-1170 or fill out our contact form.


What Is Hepatic Encephalopathy?

The liver filters toxins from the blood. When you have liver disease, ammonia and other toxins can build up in your brain, causing you to lose brain function.

This condition is hepatic encephalopathy (HE).

HE is often a complication of cirrhosis of the liver.

About 7 out of 10 people with cirrhosis develop some form of HE. The exact number is unknown because the symptoms can be subtle in the early stages.

Types of hepatic encephalopathy

There are two types of HE.

  • Acute HE comes on fast and may be a sign of liver failure.
  • Chronic HE takes longer to develop. Sometimes people recover only to have it recur later.

Doctors classify the severity of HE by stages.

  • Stage 0: Minimal HE. Slight changes in memory and concentration.
  • Stage 1: Mild HE. Mood changes and sleep problems.
  • Stage 2: Moderate HE. Inappropriate behavior, slurred speech, trouble doing basic math.
  • Stage 3: Severe HE. Disorientation, extreme sleepiness, or anxiety.
  • Stage 4: Coma.

Risk factors and complications of HE

Risk factors that make it more likely you'll get HE include:

  • Cirrhosis or other severe liver disease.
  • Having a TIPS procedure.
  • Having a previous episode of HE.
  • Having portal hypertension.

If you've had HE once, these things can trigger another bout:

  • Not drinking enough water.
  • Low levels of salt in the blood.
  • Eating too much protein.
  • Bleeding from digestive tract.
  • Infections.
  • Kidney failure.
  • Lack of potassium.
  • Low oxygen levels.
  • Surgery.
  • Taking drugs that act on the central nervous system, including antidepressants, sleeping pills, opiates, and opioids.

Untreated, HE will get worse. It will not get better on its own.

How to prevent HE

The only sure way to prevent HE is to keep your liver healthy. People who drink too much alcohol or have hepatitis are at risk for liver disease.

If you have liver disease, you can prevent further damage by:

  • Eating a healthy diet.
  • Maintaining a healthy weight.
  • Not drinking alcohol.
  • Seeing your doctor on a regular basis.

Why choose the UPMC Center for Liver Diseases for hepatic encephalopathy care?

  • Our doctors are experts at treating complications from liver disease, including HE.
  • We offer cutting-edge treatments and therapies for those with cirrhosis and other liver disease.
  • UPMC is also home to one of the most experienced liver transplant centers in the country.

Hepatic Encephalopathy Symptoms and Diagnosis

If you have liver disease, you should see your doctor at the first sign of HE. The sooner you get treatment, the more likely you are to recover.

Mild to moderate HE symptoms include:

  • Forgetfulness and confusion.
  • Inability to concentrate.
  • Moodiness, irritability, or other personality changes.
  • Inappropriate behavior.
  • Slurred speech.
  • Trouble doing basic math or writing.
  • Sleeping during the day.
  • Musty, sweet breath.

Severe symptoms of HE include:

  • More pronounced confusion.
  • Anxiety or fearfulness.
  • Depression.
  • Feeling disoriented.
  • Inability to do basic mental tasks.
  • Extreme sleepiness.
  • Sluggish movement.
  • Shaking of arms or hands (“flapping").
  • Jumbled speech.

Diagnosing hepatic encephalopathy

There is no diagnostic test for HE. Instead, doctors will rule out other possible problems. Your doctor will do a physical exam and talk to you about your health history.

Your doctor may order these tests:

  • Blood tests help identify ammonia levels and other abnormalities associated with liver disease.
  • Imaging tests such as CT and MRI scans measure the electrical activity of the brain.
  • Liver function tests check enzyme levels that show stress on your liver.

Hepatic Encephalopathy (HE) Treatment

The specialists at the UPMC Center for Liver Diseases treat HE as early as possible for best results.

Treatment involves medicine and lifestyle changes. One goal is to reduce the amount of ammonia in the blood.

Medicine to treat HE

Doctors treat HE with lactulose and antibiotics to reduce the levels of ammonia and other toxins in the blood.

  • Lactulose draws ammonia into your colon, where it will pass out of your body.
  • Antibiotics stop the growth of some bacteria that create toxins.

Diet changes

If you have HE, you should avoid drinking alcohol.

A dietician may also suggest nutritional changes. Eating too much protein produces an excess of ammonia in the blood. You may need to avoid eating meat and eggs.

Liver transplant

In severe cases of HE, you may need a liver transplant.