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Hepatic Encephalopathy (HE)

What is Hepatic Encephalopathy (HE)?

Hepatic encephalopathy (HE) refers to the changes in the brain that occur in patients with advanced, acute or chronic liver disease and 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 things your liver does is to change harmful substances in the body to make them harmless. However if the liver is unable to fully function these  'toxins' can build up in the bloodstream. HE occurs when the liver cannot remove certain toxins and chemicals such as ammonia from the blood. These then enter the brain and can cause both physical  and mental changes such as HE. Certain factors can trigger an episode of HE in liver patients - see our publication for full details.

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:

  • mild 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 is important to seek advice from your doctor as soon as your symptoms begin. If you have already been diagnosed with HE and you feel like your condition is worsening then seek medical help as soon as possible.


HE is a treatable condition however the severity of the condition and any causes of the episode will determine the treatment that a person will be given.

The first step will be to identify and then treat any factors that have caused the HE episode. Then, once this has been treated the 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 usually  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 some bacteria which produce ammonia in the bowel.

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

Rifaximin - a specific type of this antibiotic is used to stop the growth of certain bacteria in the gut and is usally 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. Patients with severe repeated cases of HE may be advised to reduce the amount of protein in their diet but it is important that this is only done on medical advice as a lack of protein can cause malnutrition.

Alcohol and smoking are dangerous to anyone with liver problems.

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

HE snapshot  

Download publication:  Hepatic Encephalopathy HE0117

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.