West Haven Criteria for Hepatic Encephalopathy Staging
Standard grading system for hepatic encephalopathy in cirrhotic patients, grading 0-4. Grade 0 (covert/minimal HE) through Grade 4 (coma). Essential for treatment decisions and prognosis.
Score interpretation
No clinical HE; minimal (covert) HE is shown only by psychometric or neurophysiological testing.
→ Test for minimal HE (e.g. PHES, critical flicker frequency) if there are cognitive or driving concerns; treat precipitants; do not restrict protein (1.2–1.5 g/kg/day).
Covert HE: subtle changes without disorientation or asterixis.
→ Identify and treat precipitants (infection, GI bleeding, constipation, electrolytes, sedatives, diuretics); consider lactulose; advise on driving; review.
Overt HE: disorientation to time, personality change or asterixis.
→ Admit; treat precipitants; lactulose (adults: 25 mL every 1–2 h) until ≥ 2 soft stools, then titrate to 2–3 soft stools a day; after recovery continue lactulose, and add rifaximin (adults: 550 mg twice daily) after a second episode (AASLD/EASL 2014; NICE TA337). Children: use a children's formulary.
Severe overt HE: semi-stupor, gross disorientation or coma.
→ HDU/ICU; protect the airway (intubate if not protecting it); lactulose via nasogastric tube; treat precipitants; early hepatology/transplant discussion.
Interpretation bands for the West Haven HE. Apply clinical judgement and local guidance.
References
- Vilstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by AASLD and EASL. Hepatology. 2014;60(2):715-735.
- NICE TA337. Rifaximin for preventing episodes of overt hepatic encephalopathy. NICE. 2015.
Related
Curated clinical cross-links plus same-class fallbacks.
- Lactulose · Osmotic laxative / Ammonia reduction (hepatic encephalopathy)
- Lactulose (Hepatic Encephalopathy) · Osmotic Laxative / Ammonia-Reducing Agent
- Rifaximin · Non-Absorbable Antibiotic (Hepatic Encephalopathy / IBS-D)
- Lactulose (Paediatric) · Osmotic Laxative — Constipation / Hepatic Encephalopathy
- Methotrexate (Dermatology — Psoriasis) · Disease-Modifying Antirheumatic / Immunosuppressant
- Thiamine (IV/IM — Pabrinex) · Vitamin B1 (Thiamine) — deficiency treatment / Wernicke's encephalopathy prevention
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.