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gi.hepatic-encephalopathy.core.v1

Hepatic Encephalopathy (acute episode + chronic maintenance)

gastroenterologyacutechronicadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Comprehensive HE dossier (acute episode + chronic maintenance). STEP 3 deepened (2026-05-16): design brief + research bundle authored (§5.5 items 1-2); §5.5.1 effect sizes wired (rifaximin breakthrough HE 22% vs 46%, HR ~0.42 recurrence / ~0.50 hospitalisation Bass NEJM 2010 PMID 20335583; protein 1.2-1.5 g/kg not restricted per AASLD/EASL 2014; covert-HE prevalence ~20-80%); §5.5.2 precipitant Bayesian prior (infection/SBP highest-prior → paracentesis load-bearing), ammonia conditional-independence/unstable-LR note, structural-lesion + Wernicke pivots, gi.cirrhosis + workup.sbp_workup routing. last_reconciled 2026-05-16 (AASLD/EASL 2014 + ISHEN 2014 + EASL 2018 floor; no superseding society HE guideline). Re-promoted SCAFFOLDED→PRODUCTION (design_brief present; all completeness tiers satisfied; verified via dossier:audit). RxCUIs pending research:rxnav drug-data commit.

Entry points (6)

  • symptom
    Confusion, asterixis, or personality change in cirrhotic
    confusion_asterixis
  • symptom
    Sleep-wake reversal or day-night inversion
    sleep_wake_reversal
  • symptom
    Progressive somnolence or coma in liver disease
    somnolence_coma
  • lab_abnormality
    Elevated ammonia in known cirrhosis (note: not required for diagnosis per AASLD/EASL 2014)
    hyperammonemia
  • problem_list
    Known HE on problem list — recurrence or follow-up
    hepatic_encephalopathy
  • history
    History of prior HE episode — secondary prophylaxis trigger
    prior_he_episode

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    Frailty, transplant eligibility, differential diagnosis
  • sbprequired
    vital • used at CONTEXT
    Hypotension suggests GI bleed or sepsis as precipitant (AASLD/EASL 2014)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia screens for infection/bleed precipitant (AASLD/EASL 2014)
  • temprequired
    vital • used at CONTEXT
    Fever screens for infection precipitant — most common trigger (AASLD/EASL 2014)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxia in grade 3-4 HE — airway protection assessment
  • ammonia
    lab • used at INITIAL_WORKUP
    Supportive but NOT required for HE diagnosis; normal ammonia does not exclude HE (AASLD/EASL 2014)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI/HRS as precipitant; MELD-Na component (AASLD/EASL 2014)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia as precipitant; MELD-Na component (AASLD/EASL 2014)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hypokalemia from diuretics precipitates HE via renal ammoniagenesis (AASLD/EASL 2014)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia as precipitant in advanced liver disease
  • cbcrequired
    lab • used at INITIAL_WORKUP
    WBC for infection screen; Hgb for GI bleed precipitant (AASLD/EASL 2014)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    MELD-Na severity; worsening jaundice = decompensation (AASLD/EASL 2014)
  • inrrequired
    lab • used at INITIAL_WORKUP
    MELD-Na component; coagulopathy severity (AASLD/EASL 2014)
  • urinalysis
    lab • used at BRANCHING_WORKUP
    UTI as infection precipitant screen (AASLD/EASL 2014)
  • cxr
    imaging • used at BRANCHING_WORKUP
    Pneumonia as infection precipitant screen (AASLD/EASL 2014)
  • west_haven_graderequired
    history • used at CONTEXT
    West Haven grade 0-IV classification drives treatment intensity (AASLD/EASL 2014; ISHEN 2011)
  • precipitant_screenrequired
    history • used at CONTEXT
    Infection, GI bleed, constipation, medications (opioids/benzos/sedatives), dehydration, electrolyte imbalance, TIPS, dietary protein excess (rare) (AASLD/EASL 2014)
  • lactulose_adherencerequired
    history • used at CONTEXT
    Nonadherence to lactulose is most common cause of recurrent HE (AASLD/EASL 2014)
  • prior_he_episodesrequired
    history • used at CONTEXT
    Recurrent (≥2 bouts in 6 months) vs episodic — drives secondary prophylaxis decision (Bass NEJM 2010)
  • current_medsrequired
    medication • used at CONTEXT
    Opioids, benzodiazepines, sedatives, diuretics as precipitants; verify lactulose/rifaximin compliance (AASLD/EASL 2014)

12-phase flow (12)

  1. 1FRAME
    Confirm hepatic encephalopathy scope; classify as overt (West Haven ≥2) vs covert (minimal/grade 1 — prevalence ~20-80% of cirrhotics by detection method, independently predicts overt HE and impaired driving/QoL); episodic vs recurrent vs persistent (AASLD/EASL 2014 PMID 25042402; ISHEN 2011)
    inputs: west_haven_grade, prior_he_episodes
    advance: HE type classified (overt/covert, episodic/recurrent/persistent)
  2. 2ENTRY
    Recognize confusion, asterixis, sleep-wake reversal, somnolence, or coma in patient with liver disease (AASLD/EASL 2014)
    inputs: age
    advance: HE clinically suspected in cirrhotic patient
  3. 3CONTEXT
    Vitals, West Haven grading, precipitant screen (infection, GI bleed, constipation, meds, dehydration, electrolytes, TIPS), lactulose adherence, medication review (AASLD/EASL 2014)
    inputs: sbp, hr, temp, west_haven_grade, precipitant_screen, lactulose_adherence, current_meds
    advance: West Haven grade assigned and precipitant screen initiated
  4. 4RED_FLAGS
    Grade 3-4 HE (stupor/coma) — airway protection, ICU; GI bleed with hemodynamic instability; sepsis; cerebral edema in ALF (AASLD/EASL 2014)
    inputs: spo2, sbp
    advance: grade 3-4 escalated to ICU or excluded
  5. 5INITIAL_WORKUP
    CBC, BMP (Cr/Na/K/glucose), LFTs, INR, ammonia (SUPPORTIVE ONLY — NOT required for diagnosis or monitoring; LR too unstable, confounded by sampling/transport technique; normal value only weak supportive datum against HE), blood cultures, UA, CXR. Precipitant-search prior: infection (esp. SBP) is the highest-prior single precipitant → diagnostic paracentesis if ascites (PMN ≥250/mm³ = SBP) is load-bearing; hypokalaemia increases renal ammoniagenesis → correct K (AASLD/EASL 2014 PMID 25042402)
    inputs: creatinine, sodium, potassium, glucose, cbc, total_bilirubin, inr, ammonia
    actions: panel.renal, panel.lft, panel.cbc
    advance: baseline labs returned and precipitant workup initiated
  6. 6BRANCHING_WORKUP
    Diagnostic paracentesis if ascites (SBP precipitant); CT head if focal neuro signs or no improvement at 48h (exclude SDH/stroke); EGD if GI bleed suspected (AASLD/EASL 2014)
    inputs: urinalysis, cxr
    actions: workup.sbp_workup, workup.encephalopathy
    advance: precipitant identified or excluded
  7. 7DIFFERENTIAL
    Exclude non-HE causes of AMS in cirrhotic: Wernicke, hypoglycemia, SDH/ICH, hyponatremia, medication toxicity, septic encephalopathy, post-ictal, uremia (AASLD/EASL 2014)
    advance: alternative AMS causes excluded
  8. 8RISK_STRATIFICATION
    West Haven grade (0-IV) drives treatment intensity; MELD-Na for overall liver severity; CLIF-C if ACLF suspected; number of prior episodes for prophylaxis decision (AASLD/EASL 2014)
    inputs: total_bilirubin, inr, creatinine, sodium
    actions: calc.meld_na
    advance: West Haven grade + MELD-Na documented
  9. 9TREATMENT
    Lactulose titration to 2-3 soft BMs/day (first-line; over-titration → dehydration which itself precipitates HE); rifaximin 550 mg BID add-on for recurrent HE — breakthrough HE 22% vs 46% placebo, HR ~0.42 for recurrence and HR ~0.50 for HE-related hospitalisation over 6 mo (Bass NEJM 2010 PMID 20335583); treat precipitant (abx for infection/SBP, control bleed + SBP prophylaxis, hold sedatives, correct hypokalaemia/volume); protein NOT restricted — 1.2-1.5 g/kg/day, restriction worsens sarcopenia/outcomes (AASLD/EASL 2014 HE guideline PMID 25042402)
    inputs: west_haven_grade, precipitant_screen
    advance: lactulose started + precipitant treatment initiated
  10. 10DISPOSITION
    ICU for grade 3-4 (airway risk); floor for grade 1-2 with active precipitant; outpatient for covert HE or stable recurrence on prophylaxis (AASLD/EASL 2014)
    inputs: west_haven_grade
    advance: disposition assigned
  11. 11MONITORING
    West Haven grade q4-8h inpatient; lactulose titration to 2-3 BMs/day; ammonia trend (NOT as sole guide); daily BMP for electrolytes; monitor for over-sedation from lactulose excess (AASLD/EASL 2014)
    inputs: creatinine, sodium, potassium
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Secondary prophylaxis: lactulose + rifaximin indefinitely for recurrent HE (Bass NEJM 2010); hepatology q1-3mo; transplant evaluation; driving fitness assessment; caregiver education; nutrition counselling — high protein, NOT restricted (ISHEN 2014)
    advance: follow-up and prophylaxis plan set