Hepatic encephalopathy (HE) represents brain dysfunction initiated by liver insufficiency and/or portosystemic shunts. Around 30%-40% of patients with cirrhosis show overt HE during their lifetime. 

Although the pathophysiology of HE remains unclear, its three critical factors are known: hyperammonaemia, systemic inflammation, and oxidative stress by glutaminase gene alterations. 

Minimal HE is described by the presence of signs of cognitive abnormalities in a patient without asterixis or disorientation, which can only be diagnosed with neuropsychological or psychometric tests. Overt HE is diagnosed based on clinical examination with clinical scales. 

Presently, only overt HE should be routinely treated. Treatment in an acute episode should aim to improve the mental status, identify and treat the precipitating factor, reduce duration, and limit consequences. Treatment strategies must target reducing ammonia production and/or increasing its elimination. 

Although minimal HE negatively affects the patient′s quality of life and prognosis, treatment indications are still controversial. We still need to explore much regarding the pathophysiology and management of HE. Further, we should also attempt to develop more accurate and objective diagnostic methods for overt HE that will help early detection and improve outcomes on quality of life and economic burden.

Vidal-Cevallos P, Chávez-Tapia NC, Uribe M. Current approaches to hepatic encephalopathy. Ann Hepatol. 2022 Sep 14;27(6):100757. doi: 10.1016/j.aohep.2022.100757. Epub ahead of print. PMID: 36115576.