West Haven Criteria

Select Clinical Grade

Select the grade that best describes the patient's current neurological status:

Grade 0 — Covert / Minimal HENo detectable change in personality or behaviour. Normal consciousness, attention, motor function. Abnormalities detectable only on psychometric testing (NCT, CFF).

Grade 1 — Mild (Overt HE)Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Euphoria or anxiety. Altered sleep rhythm.

Grade 2 — Moderate (Overt HE)Lethargy or apathy. Disorientation for time (≥3 of 4 wrong). Obvious personality change. Inappropriate behaviour. Asterixis present.

Grade 3 — Severe (Overt HE)Somnolence to semi-stupor. Responds to verbal stimuli. Gross disorientation. Bizarre behaviour. Asterixis usually present.

Grade 4 — Coma (Overt HE)Unresponsive to verbal or noxious stimuli. No asterixis. Decerebrate or decorticate posturing may be present.

—

West Haven Grade

Select a grade above and confirm

Grade Descriptions

Grade	Consciousness	Orientation	Asterixis	Key Features
0	Normal	Normal	Absent	Abnormal on psychometric testing only
1	Normal	Normal	May be absent	Shortened attention, sleep disturbance
2	Lethargic	Disoriented for time	Present	Personality change, inappropriate behaviour
3	Semi-stupor	Grossly disoriented	Usually present	Responds to stimuli only
4	Coma	—	Absent (coma)	No response to pain/voice

Management by Grade

Grade	Setting	Key Interventions
0–1	Outpatient	Treat precipitants, lactulose, dietary protein advice, rifaximin if recurrent
2	Inpatient ward	Lactulose, rifaximin, treat all precipitants, monitor airway
3	HDU / ICU	Airway protection, NG lactulose, rifaximin, urgent precipitant treatment
4	ICU (intubate)	Intubation, lactulose via NGT, rifaximin, manage cerebral oedema, transplant evaluation

Common Precipitants

Gastrointestinal bleeding (most common — increases intestinal ammonia)
Infection (SBP, UTI, pneumonia — look for fever, leucocytosis)
Constipation
Electrolyte disturbance (hyponatraemia, hypokalaemia)
Benzodiazepine or sedative use
Renal failure (hepatorenal syndrome, dehydration)
Excessive dietary protein
Portosystemic shunts (TIPS, surgical)

Covert vs Overt HE

Covert HE (Grade 0, also called Minimal HE): only detectable with psychometric tests — Number Connection Test (NCT-A, NCT-B), Critical Flicker Frequency, Inhibitory Control Test
Overt HE: Grades 1–4, clinically detectable
Covert HE affects driving, quality of life, and predicts future overt episodes

Lactulose and Rifaximin

Lactulose: first-line; titrate to 2–3 soft stools/day; over-purgation causes hypernatraemia
Rifaximin 550 mg BD: significantly reduces recurrence of overt HE (NEJM 2010, Bass NM et al.); now standard second-line/combined agent

References

Ferenci P, et al. Hepatic encephalopathy — definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002;35(3):716–721.
Vilstrup H, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the AASLD and EASL. Hepatology. 2014;60(2):715–735.
Bass NM, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362(12):1071–1081.