History and exam
Key diagnostic factors
common
mood disturbances
Patients may experience euphoria or depression.
sleep disturbances
Patients may have sleep disturbances such as insomnia or hypersomnia.
motor disturbances
Patients may have motor disturbances such as ataxia, and extrapyramidal symptoms such as muscle rigidity, bradykinesia, hypokinesia, slow monotonous speech, and parkinsonian-like tremor.[1]
advanced neurologic deficits
Patients may have somnolence and confusion, which may be followed by unconsciousness or coma. Hyperreflexia, nystagmus, and clonus may be present in rare cases.
Other diagnostic factors
common
asterixis
Negative myoclonus, detected by extending the arms, dorsiflexing the wrist, and spreading the fingers. Not specific for HE.
spider angiomata
Physical exam findings consistent with chronic liver disease may also be present.
palmar erythema
Physical exam findings consistent with chronic liver disease may also be present.
peripheral edema
Physical exam findings consistent with chronic liver disease may also be present.
jaundice
Physical exam findings consistent with chronic liver disease may also be present.
hepatomegaly
An enlarged liver may be seen in early viral hepatitis.
ascites
Other physical exam findings consistent with chronic liver disease may also be present.
Risk factors
strong
constipation
May precipitate episodic HE.[16] The mechanism is thought to be increased absorption of nitrogenous compounds from the gut.
excessive protein intake
May precipitate episodic HE.[16] The mechanism is thought to be increased absorption of nitrogenous compounds from the gut.
opioid use
May precipitate episodic HE.[19]
diuretic overdose
May precipitate episodic HE.[19]
portacaval shunt
The incidence of HE in the 2 years after transjugular intrahepatic portosystemic shunt (TIPS) placement is up to 55%.[4]
Older patients (>65 years), those with more advanced liver disease, and those with prior episodes of HE may be at higher risk for developing HE after TIPS.
renal impairment
Patients with cirrhosis and renal impairment have a higher risk of HE.[20]
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