Suspected hepatic encephalopathy (adult with cirrhosis)
Adult with cirrhosis or a portosystemic shunt and new confusion, drowsiness or behaviour change. HE is a diagnosis of exclusion.
All Pathways
GastroenterologyManagement
Hepatic Encephalopathy in Cirrhosis (ACG 2026)
Hepatic Encephalopathy in Cirrhosis (ACG 2026): Suspected hepatic encephalopathy (adult with cirrhosis) → Check glucose now; give thiamine if at risk → ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning Check glucose now; give thiamine if at risk
No known liver disease, with new jaundice and coagulopathy: think acute liver failure and use that pathway instead.
- Low glucose: treat at once; never delay glucose to give thiamine first
- Alcohol use or malnutrition: IV thiamine before IV glucose when feasible. Adult: 300 mg daily; suspected Wernicke: 500 mg three times a day
- Think of alcohol withdrawal and Wernicke encephalopathy: they need their own treatment (in liver disease, a short-acting benzodiazepine for withdrawal)
03Action Assess and exclude other causes
Full neurological exam and GCS. Grade with West Haven criteria. Asterixis alone is not overt HE.
- Other causes: sepsis, low or high glucose, low Na, uraemia, hypoxia or high CO2, drugs, alcohol, stroke, seizure
- Bloods: Na, K, creatinine, FBC, INR, LFTs, blood cultures; urine culture
- Ascites: diagnostic paracentesis to exclude SBP
- CT brain if new focal signs, fall or head injury, seizure, or no improvement at 48-72 h
- Ammonia does not grade HE or guide treatment; a normal level should prompt a search for another cause
04Decision Overt HE (West Haven grade 2-4)?
Grade 2: lethargic, disoriented to time, inappropriate behaviour, asterixis. Grade 3: somnolent but rousable, grossly disoriented. Grade 4: coma.
- If Yes
- Overt HE (grade 2-4)
05Action Overt HE: decide where to treat
Admit if first episode, a precipitant needs work-up or treatment, grade 3-4, agitated, or no reliable carer.
- Outpatient care only if grade 2 or less, a typical repeat episode, no precipitant to work up, and reliable support with close review
06Warning Grade 3-4 (somnolent or coma): HDU or ICU; protect the airway
High risk of aspiration. Nothing by mouth.
- Coma or cannot protect the airway: intubate in ICU
- Give lactulose by NG tube, or as a retention enema if anal tone is preserved
- Refer early to hepatology for liver transplant assessment
07Action Overt HE: find and treat the precipitant
Most episodes have one. Treating it can reverse HE.
- Infection, including SBP: cultures; start antibiotics if infection is suspected
- GI bleeding: follow the GI bleeding pathway
- Sedating drugs (opioids, benzodiazepines, gabapentinoids, Z-drugs): stop or reduce. Long-term benzodiazepine: taper, do not stop abruptly (withdrawal seizures)
- Dehydration, over-diuresis or AKI: hold diuretics and nephrotoxins; correct volume
- Low K; high glucose; low Na: correct Na by no more than 8 mmol/L a day
- Constipation, hypoxia, recent TIPS
- Do not restrict protein
08Action Overt HE: lactulose (adult), titrate to 2-3 soft stools a day
First line. Do not give if bowel obstruction or perforation is suspected, or in galactosaemia.
- Lactulose 3.34 g/5 mL: 15-30 mL (10-20 g) oral or NG every 2 h until 2 soft stools
- Then 15-30 mL 2-4 times a day to keep 2-3 soft stools a day
- Enema (anal tone preserved): 300 mL lactulose in 700 mL water or saline; retain 30-60 min; repeat every 4-6 h until mental state improves
- Over-use causes dehydration, high Na, low K and aspiration: monitor Na, K and creatinine
- Alternative if lactulose is not tolerated (bloating, distension): high-volume PEG 3350 electrolyte solution (e.g. 4 L)
- ICU with a faecal management system: hold lactulose if stool is over 300 mL a day
09Action Overt HE: add rifaximin 550 mg oral twice a day (adult)
Add to lactulose, not instead of it. Suggested in acute overt HE; recommended after a recurrence on lactulose.
- Nil by mouth (grade 3-4): lactulose by NG or enema comes first; give rifaximin by NG only if the pharmacist advises, or start when the patient can swallow safely
- Australia: PBS Authority Required: prior HE episodes, with lactulose if tolerated, gastroenterologist or hepatologist
- Prevention trial: 58% fewer breakthrough episodes (NNT 4)
10Decision Mental state improving within 48-72 h?
Reassess West Haven grade and GCS; titrate lactulose to stool output.
- If Yes
- Improving
11Action Improving: plan discharge and prevent recurrence
Secondary prophylaxis starts after the first overt episode.
- Lactulose to 2-3 soft stools a day (first line); use a Bristol stool chart
- Rifaximin 550 mg twice a day: add after a recurrence on lactulose; may be used after the first episode (Australia: PBS criteria)
- Stop or reduce sedatives, opioids and gabapentinoids at discharge
- Protein 1.2-1.5 g/kg/day and a late-evening snack; no protein restriction
- Advise patient and carers: no driving after overt HE in the past 3 months
- Refer for liver transplant assessment if grade 3-4, recurrent HE or high MELD
12Outcome Discharge on HE prophylaxis with early clinic review
Return at once for new confusion, drowsiness, fever, GI bleeding or no bowel action.
If No- Not improving
13Warning Not improving at 48-72 h: look for another cause
Discuss with hepatology.
- Re-check for a missed precipitant, other causes and lactulose delivery (2-3 soft stools a day); CT brain if not done
- Large spontaneous shunt or recent TIPS: discuss shunt embolisation or TIPS reduction with hepatology and IR
- Liver transplant assessment. Low zinc despite lactulose and rifaximin: add zinc
If No- Covert HE
14Warning No overt HE (grade 0-1): admit if a precipitant needs treatment or first episode
Outpatient care only when no precipitant needs treatment and there is reliable support.
- Infection (including SBP), GI bleeding, AKI, dehydration, or low Na or K: admit and treat it (antibiotics for infection; GI bleeding pathway; hold diuretics and correct volume)
- First episode of confusion: assess in ED to exclude other causes before outpatient care
- Disoriented, lethargic or worsening: manage as overt HE (grade 2 or more)
15Action No overt HE and no precipitant needing admission: outpatient care
Exclude other causes of cognitive change first: sleep apnoea, dementia, mood disorder, drugs, alcohol.
- Consider lactulose, titrated to 2-3 soft stools a day; decide case by case
- Review sedating drugs
- Ask about driving and machinery; advise about safety
16Outcome Covert HE: clinic review; return if worse
Seek urgent care for new confusion, drowsiness, fever, GI bleeding or no bowel action.
Guideline Source
ACG Clinical Guideline: Hepatic Encephalopathy (Bajaj et al., 2026)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with cirrhosis only: not for acute liver failure or children
- HE is a diagnosis of exclusion; ammonia does not grade HE or guide treatment
- West Haven grading is subjective; use GCS as well in drowsy patients
- Rifaximin needs PBS Authority in Australia
Contraindicated Populations
Children (under 18 years)Acute liver failure (no prior chronic liver disease)Suspected bowel obstruction or perforation (lactulose)Galactosaemia (lactulose)
Applicable Regions
AUUSEUGlobal
AU: Rifaximin 550 mg (Xifaxan) is PBS Authority Required for prevention of HE: prior episodes, with lactulose if tolerated, under a gastroenterologist or hepatologist (PBS, Aug 2026). L-ornithine L-aspartate is not a TGA-registered medicine.
EU: EASL 2022 HE clinical practice guideline (J Hepatol 2022;77:807-824) applies.
US: ACG 2026 HE guideline is the current US guideline.
Version 2Next review: 2027-09-30
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Calculator
Glasgow-Blatchford Bleeding Score
Upper GI bleed risk stratification and need for intervention
Open page
Compare
AttendMe.ai vs UpToDate
See how this pathway workflow compares against UpToDate.
Open page
Commercial
Start free
Run the pathway in a live AttendMe account with citations and tracked usage.
Start free
Related Resources
Frequently Asked Questions
What is the Hepatic Encephalopathy in Cirrhosis (ACG 2026)?
The Hepatic Encephalopathy in Cirrhosis (ACG 2026) is a management clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline: Hepatic Encephalopathy (Bajaj et al., 2026).
What guideline is the Hepatic Encephalopathy in Cirrhosis (ACG 2026) based on?
This algorithm is based on ACG Clinical Guideline: Hepatic Encephalopathy (Bajaj et al., 2026) (DOI: 10.14309/ajg.0000000000003899).
What are the limitations of the Hepatic Encephalopathy in Cirrhosis (ACG 2026)?
Known limitations include: Adults with cirrhosis only: not for acute liver failure or children; HE is a diagnosis of exclusion; ammonia does not grade HE or guide treatment; West Haven grading is subjective; use GCS as well in drowsy patients; Rifaximin needs PBS Authority in Australia. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Hepatic Encephalopathy in Cirrhosis (ACG 2026) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free