West Haven Criteria for Hepatic Encephalopathy
Grades hepatic encephalopathy severity using the West Haven criteria (Grades 0–4), guiding management intensity in patients with liver disease.
Score interpretation
No clinically detectable HE. Psychometric testing may show minimal HE (covert HE = minimal HE + grade 1).
→ Identify and treat precipitants (infection, constipation, GI bleed, dehydration, sedatives). Lactulose for prophylaxis in recurrent HE. Rifaximin if ≥ 2 episodes.
Mild HE: trivial lack of awareness, euphoria or anxiety, shortened attention span, impaired addition or subtraction, altered sleep rhythm.
→ Identify precipitants. Lactulose (titrate to 2–3 soft stools/day). Rifaximin (adults: 550mg BD) if on lactulose and recurrent. Avoid benzodiazepines and opioids. Protein restriction not recommended. Children: use a children's formulary.
Moderate HE: Lethargy, personality change, obvious confusion, asterixis.
→ Admit. Identify and treat precipitants (SBP, GI bleed, drugs, constipation). Lactulose ± rifaximin. IV thiamine. Nutrition (1.2–1.5 g/kg/day protein). Hepatology review.
Severe HE: Marked confusion, somnolent but rousable.
→ HDU. Airway protection (aspiration risk). NG lactulose if swallowing impaired. IV thiamine, IV glucose, IV fluids. Treat precipitants aggressively. Hepatology consult for transplant assessment.
Coma: Not rousable. High mortality.
→ ICU. Intubation for airway protection. CT head to exclude intracerebral bleed. Lactulose via NG. Treat precipitants. Urgent liver transplant assessment if appropriate. Mannitol if cerebral oedema in ALF.
Interpretation bands for the Hepatic Encephalopathy Grade. Apply clinical judgement and local guidance.
References
- Ferenci P, et al. Hepatic encephalopathy — definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology. Hepatology. 2002;35(3):716–721.
- Vilstrup H, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by AASLD and EASL. Hepatology. 2014;60(2):715–735.
Related
Curated clinical cross-links plus same-class fallbacks.
- Lactulose · Osmotic laxative / Ammonia reduction (hepatic encephalopathy)
- Lactulose (Hepatic Encephalopathy) · Osmotic Laxative / Ammonia-Reducing Agent
- Lactulose (Paediatric) · Osmotic Laxative — Constipation / Hepatic Encephalopathy
- Dobutamine (Acute HF / Stress Echo) · Inotrope / Acute Heart Failure
- Milrinone · Inodilator / Acute Heart Failure
- Vericiguat · Heart Failure
- Upper GI Bleeding · BSG Guidelines 2019; NICE NG141
- Lower Gastrointestinal Bleed · NICE; BSG; ACPGBI — Commissioning Guide
- Acute Pancreatitis · NICE; IAP/APA; ACPGBI — CG104
- Difficult Airway Algorithm (DAS) · DAS 2015; Royal College of Anaesthetists
- Major Haemorrhage Protocol · NICE NG24; UK MHP guidelines
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.
