Hepatic encephalopathy (HE) is no longer a rare complication — it’s an urgent clinical reality that’s a leading cause of hospitalization in patients with cirrhosis1. HE can be deceptively subtle or profoundly severe, presenting with a wide clinical spectrum — from mild cognitive slowing to life-threatening coma. Without clear disease biomarkers, HE remains a diagnosis of exclusion, making it critical for clinicians to remain vigilant, especially in patients with chronic liver disease (CLD).
The incidence of CLD is climbing, fueled by rising rates of alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease (MASLD), and hepatitis C, which is often undiagnosed. For example:
- More than 2 million Americans had alcohol-associated cirrhosis as of 20172.
- Currently, 38% of all adults and 7–14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%3.
- The economic burden is staggering — from $1 billion4 in 2003 to over $7 billion5 in hospital costs for cirrhosis-related admissions today.
These figures aren’t just statistics — they represent a growing population of patients who are at risk of developing HE, sometimes without ever receiving a proper diagnosis or follow-up care.
Because HE mimics many other forms of neurological dysfunction — delirium, alcohol intoxication, diabetes-related confusion — it can be easy to miss or misdiagnose. But differentiating HE from other causes of altered mental status is critical, especially for patients who may ultimately require liver transplantation6, 7.
HE spans a wide clinical spectrum — from subtle cognitive changes to coma — and is associated with increased mortality, high readmission rates, and a sharp decline in quality of life for both patients and caregivers.
Moreover, patients frequently leave the hospital without adequate education or maintenance medication for episodic overt HE. Without coordinated follow-up between primary care, hepatology, and caregivers, these patients are at risk for recurrence.
To close these practice gaps, education is key. AGA’s course, “Missing the Mark: Hepatic Encephalopathy,” provides clinicians with up-to-date guidance on:
- The changing epidemiology of cirrhosis and undiagnosed cirrhosis for patients with liver disease.
- Assessment guidelines and best practices for HE diagnosis and management.
- How to develop transition-of-care plans with patients, caretakers, and specialty providers after an initial HE diagnosis.
Don’t wait until HE is an emergency. Equip yourself with the tools to recognize it earlier, treat it effectively, and coordinate better care.
References
Wolf, DC. Hepatic Encephalopathy. Medscape. 2020 May 1. Retrieved from: https://emedicine.medscape.com/article/186101-overview
Singal AK, Mathurin P. Diagnosis and treatment of alcohol-associated liver disease A review. JAMA. 2021;326(2):165-176. doi:10.1001/jama.2021.7683
Younossi ZM, Kalligeros M, Henry L. Epidemiology of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol. 2025 Feb;31(Suppl):S32-S50. doi: 10.3350/cmh.2024.0431. Epub 2024 Aug 19. PMID: 39159948; PMCID: PMC11925440.
Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug;60(2):715-35.
Desai AP, Mohan P, Nokes B, Sheth D, Knapp S, Boustani M, Chalasani N, Fallon MB, Calhoun EA. Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database. Clinical and Translational Gastroenterology. 2019 Jul 1;10(7):e00062.
Serper, Marina1,2; Schaubel, Douglas E.3; Cousins, Katheryn A.Q.4; McMillan, Corey4; Asrani, Sumeet5; Boike, Justin6; Yoshino Benavente, Julia7; Wolf, Michael S.7. Hepatic encephalopathy predicts early post-transplant cognitive and functional impairment: The Livcog cohort study. Hepatology Communications 9(4):e0696, April 2025. | DOI: 10.1097/HC9.0000000000000696
Montagnese S, Bajaj JS. Impact of hepatic encephalopathy in cirrhosis on quality-of-life issues. Drugs. 2019;79(Suppl 1):11–6.