saudigastro.com/patients/hepatic-encephalopathy
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Serious
Red flags
4
This article is educational and does not replace your doctor's advice. Seek urgent care for any red-flag symptoms.
What is it?
Hepatic encephalopathy (HE) is a change in brain function caused by liver disease. A healthy liver filters waste products, such as ammonia (a substance made when the body breaks down protein), out of the blood. When the liver is badly scarred or blood bypasses it, these substances reach the brain. HE ranges from very mild changes that only tests can detect, to forgetfulness, day-night sleep reversal, confusion, and in severe cases deep drowsiness or coma. It is usually reversible with treatment, but it tends to come back if the triggers and treatment are not managed.
How common is it?
HE is a common complication of cirrhosis, and a large share of people with cirrhosis experience some form of it, including mild forms that are easy to miss. Once an episode has happened, it is likely to return unless preventive treatment is taken.
Why does it happen?
HE occurs when toxins from the gut are not cleared by the liver. Episodes are often set off by a trigger: constipation, infection (urinary, chest or abdominal), bleeding in the digestive tract (blood is broken down in the gut like protein), dehydration from vomiting, diarrhoea or too much water pill (diuretic), low blood potassium or sodium, kidney problems, and sedative or sleeping medicines such as benzodiazepines or opioid painkillers. Not taking lactulose as prescribed is another common reason. Sometimes no trigger is found.
Symptoms
- Mild: trouble concentrating, slowed thinking, irritability or a "foggy" feeling
- Reversed sleep pattern: sleepy by day, awake at night
- Forgetfulness, misplacing things, trouble with familiar tasks
- Changes in personality or mood, anxiety, inappropriate behaviour
- Slurred speech, slowed movement, clumsy handwriting
- Hand flapping when arms are stretched out (asterixis)
- Disorientation: not knowing the date, place or people
- Severe drowsiness that is hard to wake, or coma
Red flags — seek urgent medical care
New confusion, strange behaviour, or someone who is hard to wake
This is an emergency in someone with liver disease. Go to the emergency department or call the ambulance (997 in Saudi Arabia).
Confusion with fever, belly pain or swelling
Infection of the fluid in the belly or elsewhere may be triggering it and needs urgent treatment.
Confusion with vomiting blood or black stools
Digestive bleeding. Emergency.
Fewer than two soft bowel motions a day while on lactulose, or severe diarrhoea
Dose may need adjusting. Constipation can trigger HE, and diarrhoea can cause dehydration. Call your team.
How is it diagnosed?
HE is mainly diagnosed from your story and examination in someone known to have liver disease. Your doctor will check alertness, orientation, speech and hand tremor, and look for a trigger with blood tests (kidney function, salts, glucose, infection markers), urine and chest tests, and sometimes a sample of fluid from the belly. Other causes of confusion, such as low blood sugar, stroke, drug effects or severe infection, must be excluded, sometimes with a brain scan. Blood ammonia levels are not needed to make the diagnosis in most cases. Mild forms may be picked up with simple attention or reaction-time tests.
Outlook — what to expect
Most episodes improve when the trigger is found and treated and lactulose is started or optimised. Because HE usually comes back without preventive treatment, long-term lactulose, sometimes with rifaximin, is advised after an episode. Repeated or severe HE shows that the liver disease is advanced, and is a reason to talk to your specialist about liver transplant assessment. It also affects safety, work and independence, so early treatment matters.
Treatment
Habits & Lifestyle
Most prevention comes from avoiding triggers, taking your medicine regularly and involving your family.
- Aim for regular soft bowel motions every day (your doctor usually advises about two to three). Do not let constipation continue.
- Do not take sleeping tablets, sedatives, tranquillisers or opioid painkillers unless your liver doctor has approved them. Check before any new medicine.
- Avoid alcohol completely.
- Treat infections early: see a doctor quickly for fever, urinary symptoms, cough or abdominal pain.
- Do not drive or operate machinery if you have had HE, unless your doctor says it is safe. Even mild HE can slow reactions without you noticing, and the same goes for climbing, cooking over a flame, or swimming alone.
- Ask your family to learn the warning signs and to call your team early.
Diet
Older advice to cut protein is now considered harmful. People with cirrhosis need enough protein and calories to protect their muscles, and muscle loss itself can worsen HE.
- Eat enough protein and calories. Several smaller meals and a late-evening snack are better than long gaps without food. A dietitian can tailor this.
- Vegetable and dairy proteins are often well tolerated and your dietitian may suggest including them.
- Eat fibre (vegetables, fruit, whole grains) and drink enough fluids to prevent constipation, unless your doctor limits fluids for another reason.
- If you also have ascites, follow your salt limits but do not cut back on overall food.
Medications
Treatment aims to clear toxins from the gut and prevent the next episode. These medicines are prescribed and adjusted by your doctor.
- Lactulose is the standard treatment. It is a sugar that is not absorbed, works as a laxative and changes the gut so that fewer toxins are absorbed. The aim is usually a few soft stools daily, not diarrhoea. Never stop lactulose on your own, even if you feel well, because that is a common cause of relapse.
- Rifaximin is an antibiotic that mostly stays in the gut. It is typically added to lactulose if HE comes back, to lower the chance of further episodes.
- If you have diarrhoea, dizziness or are not eating or drinking, call your team: the lactulose dose may need to be lowered and dehydration treated.
- Your doctor will review water pills, sedatives and other medicines that may trigger HE.
Procedures & Surgery
No procedure is needed for most people; treatment is medicines and fixing the trigger. Hospital care is needed for more severe episodes.
- Hospital admission for moderate to severe HE: treatment of the trigger, fluids, lactulose (sometimes by enema), monitoring, and intensive care if consciousness is very low.
- Treating bleeding or infection with endoscopy or antibiotics when these are the cause.
- In some people with repeated HE, doctors may check for blood vessels that bypass the liver or discuss liver transplant evaluation.
Living with the condition
- Ramadan: speak to your liver team well before Ramadan. Fasting can cause dehydration and constipation and interrupt lactulose doses, which may trigger HE, so your plan must be individualised and fasting may not be advised.
- Tell family, close friends and your employer what HE is and what to do in an emergency.
- Arrange alternative transport if you cannot drive, and ask about support if your work is affected.
- Keep a written list of medicines, including the dose of lactulose that works for you.
In the Saudi context
Lactulose and rifaximin are available through hospital and community pharmacies in Saudi Arabia, and coverage differs between facilities, so ask your pharmacist and clinic early if supply is a problem rather than stopping treatment. Many families live together, which makes it easier to share the job of watching for confusion and for medicine reminders.
Questions to ask your doctor
Save this list or print it before your appointment — doctors appreciate prepared patients.
- What triggered my episode, and how can I avoid it?
- How many bowel motions a day should I aim for on lactulose?
- Do I need rifaximin as well?
- Is it safe for me to drive or work?
- How should I manage my medicines if I want to fast in Ramadan?
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Status: Approved for publication by SGA; individual clinician review is ongoing · Published 24/04/2026
For general education only; it does not replace your doctor’s advice. Individual clinician review of this guide is ongoing. SGA clinician? Review this guide