by EBSCO Medical Review Board
(Encephalopathy, Hepatic; Portal-Systemic Encephalopathy; Encephalopathy, Portal-Systemic)


Hepatic encephalopathy is a problem with the brain in people who have liver disease. The problem may be temporary or permanent.

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A diseased liver cannot filter the harmful items in blood. These toxins build up in the blood, which reaches the brain and affects the brain’s ability to work as it should.

Risk Factors

This problem is more common in people with:

  • Severe cirrhosis , especially after shunt surgery
  • Hepatitis—infectious or autoimmune

In these people, it may be triggered by:

  • Problems that affect the body's levels of fluids and electrolytes, such as hyponatremia and hyperkalemia
  • Bleeding in the stomach and intestines
  • Infection
  • Certain medicines, such as sedatives and anti-epileptics
  • Kidney failure
  • Constipation


There may not be symptoms in the early stages. As the disease gets worse, problems may be:

  • Problems sleeping
  • Tiredness
  • Lack of focus
  • Memory problems
  • Confusion
  • Movements that cannot be controlled, such as a flapping tremor of the hands
  • Slurred speech
  • Changes in behavior and personality
  • Depression or anxiety
  • Loss of alertness


You will be asked about your symptoms and health history. A physical exam will be done. Your blood will be tested to find out how well your liver and kidneys are working.

There are no specific tests to diagnose this health problem. Tests will be done to look for other health problems that may be causing your symptoms.

Images of the brain will be taken. This can be done with:

  • CT scan
  • MRI scan


The goal of treatment is to lower the amount of toxins in the blood. Options are:

Emergency Care

Initial care will be needed to find and correct any underlying health problems that are causing symptoms. This may mean removing or neutralizing toxins in the blood.


Medications may be used to:

  • Neutralize toxins in the intestine, such as ammonia
  • Reduce ammonia made by intestinal bacteria
  • Remove blood from the intestines
  • Treat the health problem that started the encephalopathy
  • Lower the risk of this happening again

Dietary Changes

Dietary changes may be needed. For example, tube feeding may be used to improve nutrition.


If this problem is due to liver failure, a liver transplant may be needed.


To lower the risk of this health problem:

  • Manage chronic liver problems.
  • Limit or avoid alcohol to improve liver health.
  • Take medicines as advised.
  • Avoid being exposed to poisons or toxins.
  • Do not use illegal drugs.


National Digestive Diseases Information Clearinghouse 

National Institute of Neurological Disorders and Stroke 


Canadian Liver Foundation 

Health Canada 


Hepatic encephalopathy. Canadian Liver Foundation website. Available at: Accessed July 21, 2021.

Hepatic encephalopathy. Cleveland Clinic website. Available at: Accessed July 21, 2021

Hepatic encephalopathy. EBSCO DynaMed website. Available at: Accessed July 21, 2021.

Liere V, Sandhu G, et al. Recent advances in hepatic encephalopathy. F1000Res. 2017;6:1637.

Liotta EM, Kimberly WT. Cerebral edema and liver disease: classic perspectives and contemporary hypotheses on mechanism. Neurosci Lett. 2020;721:134818.

Revision Information

  • Reviewer: EBSCO Medical Review Board Rimas Lukas, MD
  • Review Date: 07/2021
  • Update Date: 07/21/2021