[135] Likewise, episodes of OHE may be associated with persistent cumulative deficits in WM and learning.[14] Hepatic encephalopathy should be classified according to all of the following four factors.[10] According to the underlying disease, HE is subdivided into Type A resulting from ALF Type B resulting

predominantly from portosystemic bypass or shunting Type C resulting from cirrhosis The clinical manifestations of types Adriamycin nmr B and C are similar, whereas type A has distinct features and, notably, may be associated with increased intracranial pressure and a risk of cerebral herniation. The management of HE type A is described in recent guidelines on ALF[62, 63] and is not included in this document. According to the severity of manifestations. The continuum that is HE has been arbitrarily subdivided. For clinical and research purposes, a scheme of such grading is provided (Table 2). Operative classifications that refer to defined functional impairments aim at increasing intra-

and inter-rater reliability and should be used whenever possible. According to its time course, HE is subdivided into Episodic HE Recurrent HE denotes bouts of HE that occur with a time interval of 6 months or less. Persistent HE denotes a pattern of behavioral alterations that are always present and interspersed with relapses of see more overt HE. According to the existence of precipitating factors, HE is subdivided into Nonprecipitated or Precipitated, and the precipitating factors should be specified. Precipitating factors can be identified in nearly all bouts of episodic HE type C and should be actively sought and treated when found (Table 3). No universal criteria for diagnosis Local standards and expertise required Trivial lack of awareness Euphoria or anxiety Shortened attention

span Impairment of addition or subtraction Altered sleep rhythm Lethargy or apathy Disorientation for time Obvious personality change Inappropriate behavior Dyspraxia Asterixis Somnolence to semistupor Responsive to stimuli Confused Gross disorientation Bizarre behavior A fifth classification, according to whether or not the patient has acute-on-chronic liver failure (ACLF), has recently tuclazepam been suggested.[64] Although the management, mechanism, and prognostic impact differ, this classification is still a research area. The diagnosis requires the detection of signs suggestive of HE in a patient with severe liver insufficiency and/or PSS who does not have obvious alternative causes of brain dysfunction. The recognition of precipitating factors for HE (e.g., infection, bleeding, and constipation) supports the diagnosis of HE. The differential diagnosis should consider common disorders altering the level of consciousness (Table 4). 1.