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 clinically apparent HE -- subclinical impairment may be detectable by psychometric testing
→ Treat underlying cirrhosis and precipitants; PHES (Psychometric Hepatic Encephalopathy Score) or critical flicker frequency for formal diagnosis of minimal HE; driving assessment (DVLA notification for HE); lactulose 15-30 mL BD-TDS if minimal HE confirmed on testing; rifaximin 550 mg BD for secondary prevention if >= 2 previous overt HE episodes (NICE: approved after first episode in clinical practice); nutrition: high protein 1.2-1.5 g/kg/day (avoid protein restriction); BCAA supplementation if protein intolerant; assess for liver transplant.
Overt hepatic encephalopathy -- treat precipitant and initiate pharmacological management
→ Hospital admission; identify and treat precipitant: infection (blood cultures, CXR, SBP prophylaxis -- cefotaxime 4 g IV BD or tazocin for SBP); GI bleeding (octreotide, endoscopy); constipation (lactulose enema if very constipated); correct electrolytes (Na+, K+, Mg2+); lactulose 15-45 mL every 2 hours until 2 soft stools per day (target pH 6 with pH strips if available); rifaximin 550 mg BD for HE prevention if >= 2 episodes; ammonia level (diagnostic but does not affect management); protein NOT restricted -- 1.2-1.5 g/kg/day with BCAA if needed; late evening snack (LES) to reduce catabolic periods; avoid sedatives (benzodiazepines contraindicated -- may precipitate Grade 3-4).
Severe hepatic encephalopathy or coma -- ICU/HDU admission and airway protection required
→ ICU/HDU admission; airway protection: Grade 4 = intubation; position head at 30 degrees; IV lactulose if NG tube in place (30 mL 4-hourly, adjust to 2-3 soft stools/day); rifaximin 550 mg BD via NG; treat precipitant aggressively; flumazenil 0.5-1 mg IV if benzodiazepine overdose suspected (diagnostic and therapeutic, short duration); PRBC transfusion if Hb < 70 g/L; ICP monitoring if fulminant hepatic failure (Grade 3-4 in ALF); MARS liver support or molecular adsorbent recirculating system (MARS) for bridging to transplant in selected patients; transplant team urgent contact; ornithine phenylacetate (PHOENICS trial) -- emerging therapy; avoid lactulose enemas if paralytic ileus; sedation: propofol preferred if needed (hepatically metabolised less than benzodiazepines); SOFA score documentation; daily sodium assessment (hyponatraemia common, avoid rapid correction).
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.