Liver Lineup: Early Detection of Hepatic Encephalopathy

Welcome back to Liver Lineup!

Guideline author Jasmohan Bajaj, MD, MS, of Virginia Commonwealth University, rejoins hosts Nancy Reau, MD, of Rush University Medical Center, and Kimberly Brown, MD, of Henry Ford for part 2 of this 3-part series.

After a first segment focused largely on diagnosis and inpatient management, the conversation shifts upstream to the outpatient clinic.² The goal, as Reau framed it, is identifying HE before a patient is found down at home or brought to the emergency department confused.

Which Patients With Cirrhosis Should Be Prioritized for HE Testing?

Bajaj opened one step earlier in the cascade, with patients whose cirrhosis has never been diagnosed. In a national cohort of 68,807 patients with dementia and no cirrhosis diagnosis, 12.8% had a FIB-4 index above 2.67, which his group read as a signal of undiagnosed cirrhosis and possibly reversible HE.³ Bajaj said the work grew out of 2 nursing home residents whose nodular livers were discovered only after head injuries brought them to the emergency department.

“They were out of the nursing home in like a day,” Bajaj recalled of the patients after lactulose was started. He cautioned older, comorbid patients with alcohol use or diabetes are especially vulnerable to having HE mislabeled as dementia.

For patients with established cirrhosis, Bajaj argued against testing everyone. He described 3 groups where formal cognitive testing yields the greatest return. These include patients with Child-Pugh class B or C disease, patients or families raising cognitive complaints, and active drivers or machine operators, for whom a missed diagnosis could be catastrophic.

In patients without obvious deficits, Bajaj relies on a few simple questions about sleep, appetite, and satisfaction with daily life. When patients answer well on all 3, he rarely finds treatable HE. He added he rarely refers patients for lengthy testing outside a research setting without an existing complaint, since tying the test back to a symptom improves acceptance.

How Should Clinicians Prepare Patients and Families for HE?

Brown pressed on anticipatory guidance, noting clinicians routinely counsel patients on edema, ascites, and variceal bleeding but often say little about HE. She acknowledged patients sometimes arrive in the emergency department with HE while everyone involved is surprised.

Bajaj said he alerts patients and caregivers to subtle changes rather than overt confusion: altered sleep rhythms, personality shifts, and familiar tasks taking far longer than usual. A crossword normally finished in 20 minutes now taking an hour, for example, warrants a call. Having a caregiver at the visit helps, he added, since family members often notice changes first.

He also emphasized a thorough medication review at intake. Opioids, gabapentin, and sleep aids can all contribute, and other prescribers may not know the patient now has cirrhosis. Bajaj recommended communicating directly with those clinicians about dose reduction or substitution.

Reau shared she counsels more intensively when there is evidence of clinically significant portal hypertension, such as a platelet count near 60, than in a patient with a nodular liver and normal platelets. Bajaj agreed judgment is needed to avoid overloading patients. He uses follow-up visits with advanced practice providers or video calls after 2 landmark events: the first cirrhosis diagnosis and the first HE episode.

What Role Do Quick Cognitive Tools Play in Clinic?

Reau noted she directs higher-risk patients to the Quick Stroop app, a 1-minute version of the Stroop test Bajaj developed. He also described the animal naming test, in which naming fewer than 15 animals in 1 minute suggests impairment. Because the test originated in dementia research, he cautioned it confirms cognitive impairment without distinguishing HE from other causes.

Bajaj stressed testing should take place in a separate room and be framed carefully. “It is for us to actually be properly able to guide you for therapies,” he said of how he explains the purpose to patients. Linking results to an available treatment, he added, keeps patients from feeling diminished by a difficult test.

Testing is not repeated at every visit. Bajaj performs it at intake when feasible, during transplant evaluation, or when patients or families report a change short of overt confusion.

Editors’ note: Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Disclosures for Bajaj include Bausch/Salix, Grifols, Cosmo, and others.

References:

1. Bajaj JS, Jakab SS, Jesudian AB, et al. ACG clinical guideline: hepatic encephalopathy. Am J Gastroenterol. 2026;121(3):588-618. doi:10.14309/ajg.0000000000003899
2. Liver Lineup: what’s new in the ACG hepatic encephalopathy guideline. HCPLive. October 9, 2026. Accessed November 10, 2026. https://www.hcplive.com/view/liver-lineup-what-s-new-in-the-acg-hepatic-encephalopathy-guideline
3. Silvey S, Sterling RK, French E, et al. A possible reversible cause of cognitive impairment: undiagnosed cirrhosis and potential hepatic encephalopathy in patients with dementia. Am J Med. 2024;137(11):1082-1087.e1. doi:10.1016/j.amjmed.2024.06.014