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Hepatic Encephalopathy (HE)

What is Hepatic Encephalopathy (HE)?

Hepatic encephalopathy (HE) refers to changes in the brain that occur in patients with advanced, acute (sudden) or chronic (long-term) liver disease. It is one of the major complications of cirrhosis. It can occur suddenly in people with acute liver failure but is more often seen in those with chronic liver disease.

How does HE develop?

One of the most important things the liver does is to change potentially damaging substances that are either made by or taken in by the body and make them harmless. However, if the liver is badly damaged and unable to function properly, these 'toxins' can build up in the bloodstream. If they enter the brain, they can result in a condition called hepatic encephalopathy. As well as the build-up of chemicals and toxins that cause HE, other factors, such as dehydration, constipation or an infection can also trigger an episode.

What are the symptoms?

HE symptoms can range from mild to severe and can vary from person to person. Symptoms can develop rapidly or slowly over a period of time. Patients with HE can have both physical symptoms and reduced mental function.

Mild symptoms may include:

  • confusion
  • forgetfulness
  • personality or mood changes
  • stale or sweet odour on the breath
  • poor judgement
  • poor concentration
  • change in sleep patterns
  • worsening of handwriting or small hand movements.

Severe symptoms may include:

  • unusual movements or shaking of hands or arms
  • extreme anxiety
  • seizures
  • severe confusion
  • sleepiness or fatigue
  • severe personality changes
  • jumbled and slurred speech
  • slow movement.

HE can be an emergency, so it’s important to seek advice from your doctor as soon as you notice worrying symptoms. If you’ve already been diagnosed with HE and feel as though your condition is worsening, seek medical help as soon as possible.


HE is a treatable condition. The severity of the condition and potential triggers will determine the treatment given.

The first step is to identify and treat any factors that have caused the HE episode. Once this has been addressed, your doctor may prescribe medication to help prevent future episodes. The long term aim of HE treatment is to reduce the production and absorption of toxins such as ammonia.

There are three types of medication commonly used to reduce recurring episodes of HE:

Lactulose - a type of sugar that changes the acidity of your stools to help prevent the growth of bacteria that produce ammonia in the bowel

Neomycin - a type of antibiotic which may be used to help reduce the production of ammonia by killing intestinal bacteria in the gut

Rifaximin – an antibiotic used to stop the growth of certain bacteria in the gut. It’s usually taken alongside other treatments such as lactulose.

As with all medicines these need to be taken in a certain way and can have side effects. Please see our publication for full information.

Certain medications, such as those containing ammonium, and those broken down by the liver, such as sedatives and tranquilisers, should be avoided.

Looking after yourself

Eating a healthy balanced diet and exercising to maintain a healthy weight are recommended. Current advice suggests aiming for 30 minutes of exercise at least five times a week, including some strength training. If you are overweight, it’s important to get advice on how to lose weight safely – avoid crash diets. Alcohol is processed by the liver and is dangerous for anyone with liver problems. Smoking is dangerous to everyone’s health.

For more detailed information download the publication below.


Please visit the support section of our website for information on Support groups in your area or visit our Useful Links section for other organisations who may be able to offer information and support.

Download publication


Download publication:  Hepatic Encephalopathy HE0118

BMA Patient Information Awards 2015 - Commended


View references here

Reviewed by: Dr Richard Aspinall, Consultant Hepatologist, Department of Gastroenterology and Hepatology, Queen Alexandra Hospital, Portsmouth.

Further information


The British Liver Trust has worked with Norgine to produce a Patient Passport for people with advanced liver disease who either have the symptoms of HE or are worried they may develop them. The passport aims to help you keep track of important information related to your condition and includes a ‘patient alert card’ that you can keep in your wallet so that Healthcare Professionals are aware of your condition and do not think it is caused by other factors.

You can download the passport here or contact the office for a paper copy including the alert card.

HE Time to Deliver Front page 'Time to DeLiver' report on HE which contains ten calls to action to improve the identification, treatment and management of hepatic encephalopathy;

Evidence shows that better management of Hepatic Encephalopathy (HE) leads to fewer hospital re-admissions, shorter hospital stays, improved patient experience and savings for the NHS.