Severe hepatic encephalopathy is an independent predictor of mortality in hospitalised patients with cirrhosis

Hepatic encephalopathy (HE) is one of the most debilitating complications to cirrhosis (1). It has a considerable impact on patients as well as their caregivers and the health care system. The condition is defined as a brain dysfunction caused by liver insufficiency or portal systemic shunting. The symptoms, which are potentially reversible, vary from subclinical to deep coma. Symptomatic, also known as overt HE is a marker of decompensated cirrhosis. Overt HE may be precipitated by an event such as infection or bleeding, but often, no precipitating factor is identified. Overt HE is generally graded based on the severity of the symptoms according to the four-point West Haven Scale (2). The highest (worst) grade (3 to 4) are characterised by impaired consciousness. Grade 3 HE is diagnosed in patients with somnolence/semi-stupor, who remain responsive to stimuli; are confused, show gross disorientation or bizarre behaviour. Grade 4 is defined as coma (not responsive to stimuli). According to the time course, HE is defined as episodic, recurrent or persistent. In patients with cirrhosis, the risk of developing HE is closely related to the severity of the underlying liver disease (3).