What is hepatic encephalopathy (HE)?

HE is a possible consequence of liver disease.

Photograph of a man

Liver disease happens to many people for lots of different reasons. In fact, approximately 4.5 million people in the United States have some form of liver disease.

Some of the common types of liver disease and their causes include:

  • Hepatitis is an inflammation of the liver caused by different viruses and classified as A, B, and C
  • Nonalcoholic fatty liver disease (NAFLD), which is caused by too much fat in the liver cells
  • Alcohol-related liver disease, which is the result of drinking too much alcohol

All of these types of liver disease can damage and scar the liver.

Graphic of a healthy liver
Graphic of an unhealthy liver with cirrhosis

Liver disease can lead to other, more serious problems, such as cirrhosis

Having liver disease over a long period of time may damage the liver and eventually lead to its soft, healthy tissue being replaced by hard scar tissue. This condition is called cirrhosis.

As cirrhosis becomes worse, the liver will have less and less healthy tissue. The liver is important because it filters everything that you eat and drink. It processes food into energy and nutrients that your body can use. It also gets rid of harmful substances called toxins.

Photograph of a woman

Cirrhosis can cause symptoms and complications over time, including HE

Cirrhosis may not cause any symptoms or complications at first, but over time, it can lead to many.

A liver that has been damaged cannot filter toxins out of the blood the way a healthy liver would. These toxins can build up and travel through the body until they reach the brain. It’s the buildup of these toxins in the brain that can lead to the symptoms of HE.

What are the symptoms of HE?

HE may be considered either “covert” or “overt,” depending on the severity of symptoms. When HE is covert, the symptoms are minimal and may not be noticeable, even in a doctor’s examination.

In overt HE, however, symptoms may be more noticeable to others.

The chart below shows the range of symptoms associated with HE from Grade 1, which is considered covert, to Grades 2, 3, and 4, which are considered overt HE.

Lack of awareness
Euphoria or anxiety
Shortened attention span
Difficulty with addition or subtraction
Altered sleep patterns
Lack of energy or interest
Confused sense of date and time
Obvious personality change
Inappropriate behavior
Uncoordinated movements
Tremor or flapping of the wrists
Sleepiness or stupor
Responds to stimuli
Confused sense of place, where one is
Extreme disorientation
Complete unresponsiveness (coma)

If you have an underlying liver disease condition and you start to develop any of these symptoms, it is important that you talk with your healthcare provider. Early diagnosis is important in helping you and your doctor start managing your disease.

Thumbnail image of HE Symptoms Checklist

Keep track of the symptoms of HE

Download the HE symptoms checklist

What is overt hepatic encephalopathy (HE)?

When HE symptoms are more severe, the condition is called “overt” HE. Once overt HE occurs, there is a risk of more overt HE episodes, as well as HE-related hospitalization. It’s important to understand the risks of developing overt HE, so that you understand why ongoing management can help reduce those risks.

What are the risks of overt HE?

Once an overt HE episode has occurred, there is a risk for another overt HE episode.

Once overt HE occurs, 2 in 5 patients will have a recurrence within 12 months | After an overt HE recurrence, 2 in 5 patients will have another recurrence within 6 months
  • Artistic rendering of a hospital


    Patients living with overt HE often require hospital-based care. Many will be hospitalized for HE more than once. In one study, after one episode of overt HE, there was a 40% risk of having a second episode within 1 year.
  • Artistic rendering of a brain

    Worsening symptoms

    Recent clinical trials suggest that problems with memory and learning could get worse after repeated episodes of overt HE.

How is overt hepatic encephalopathy (HE) managed?

It’s important to understand that there are certain risks involved with having overt HE. Ongoing management can help reduce those risks.

Graphic of bar chart

Reducing the risk of more overt HE episodes

Once an episode of overt HE happens, ongoing management is recommended to help reduce the risk of another episode. This is called maintenance therapy.

The focus of maintenance therapy is to reduce the toxins in the body that can lead to additional overt HE episodes. Some of the most commonly prescribed treatments are:

Artistic rendering of a bottle


Lactulose is an artificial sugar. It comes as a very sweet liquid that is taken by mouth. It can also be given as an enema for people who cannot swallow.

Lactulose works by causing more bowel movements. This helps to flush out the toxins.

An adult with overt HE will work with his/her doctor to find the right amount of lactulose to take each day so that he/she can have 2-3 bowel movements each day.

Artistic rendering of a prescription bottle


XIFAXAN is an antibiotic that stays mainly in the gut. It comes as a 550 mg tablet that is taken by mouth 2 times a day to reduce the risk of overt HE recurrence in adults.

Talk to your healthcare provider before taking XIFAXAN if you have severe hepatic (liver) impairment, as this may cause increased effects of the medicine.

Learn more about XIFAXAN

The safety and efficacy of XIFAXAN in overt HE patients has not been studied for longer than 6 months in clinical trials. If patients recover a significant amount of liver function, they may be able to discontinue HE therapy.