What are the West Haven criteria and how is hepatic encephalopathy managed?

West Haven Criteria for Hepatic Encephalopathy

Definition and Clinical Application

The West Haven criteria should be used for grading hepatic encephalopathy when at least temporal disorientation is present (grades ≥2), with the Glasgow Coma Scale added for patients with grades III-IV who have impaired consciousness. 1

The West Haven criteria represent a categorical grading system that divides hepatic encephalopathy into four grades based on the severity of neuropsychiatric manifestations. 1 While widely used, the scale has important limitations—particularly for grade I, where inter-rater reliability is poor due to the subjective nature of detecting subtle changes like psychomotor slowing and lack of attention. 1 In contrast, the detection of disorientation and asterixis (grades II and above) demonstrates good inter-rater reliability. 1

The Four Grades

Grade I

• Lack of attention 2
• Sleep disturbances 3
• Irritability 3
• Difficulty with complex cognitive tasks 4
• Subtle personality or behavior changes 4

Grade II

• Lethargy 2
• Disorientation to time (temporal disorientation) 2
• Inappropriate behavior 2
• This represents the threshold where West Haven criteria become most reliable 1

Grade III

• Somnolence 3
• Confusion 3
• Disorientation to place 2
• Patients at this grade are at risk of aspiration and should be treated in the ICU 1

Grade IV

• Coma 3
• Lack of verbal, eye, and motor response 2
• Requires intensive care monitoring due to airway compromise risk 4

Integration with Other Classification Systems

Covert vs. Overt Hepatic Encephalopathy

The modern classification distinguishes between covert HE (minimal HE plus grade I) and overt HE (grades II-IV). 1 This distinction is clinically important because:

• Covert HE includes patients with minimal or no obvious clinical signs but abnormalities on neuropsychological/neurophysiological testing 4, 3
• Overt HE begins at grade II, where temporal disorientation becomes apparent 1

For patients with mild or no neuropsychiatric abnormalities not meeting grade II criteria, neuropsychological or neurophysiological testing should be used to diagnose covert HE rather than relying on West Haven grading. 1

Complete Classification Framework

Every case of hepatic encephalopathy should be classified by four factors 1, 3:

1. Type: A (acute liver failure), B (portosystemic shunt without liver disease), or C (cirrhosis) 1, 3
2. Severity: Using West Haven criteria for overt HE 1
3. Time course: Episodic, recurrent (>2 episodes within 6 months), or persistent 1, 3
4. Precipitating factors: Constipation, GI bleeding, infections, hyponatremia, dehydration/diuretic overdose 1, 3

Diagnostic Approach by Grade

For Grades II-IV (Overt HE)

• Clinical examination using West Haven criteria is sufficient for diagnosis 1
• Add Glasgow Coma Scale for grades III-IV to provide more objective assessment of consciousness level 1
• Brain imaging (CT/MRI) should be performed if diagnostic doubts exist or if there is non-response to treatment 1
• Plasma ammonia measurement should be performed, as a normal value brings the diagnosis of HE into question 1

For Grade I and Minimal HE (Covert HE)

• West Haven criteria have limited reliability at this level 1
• Neuropsychological testing (such as psychometric hepatic encephalopathy score) or neurophysiological testing is required 1, 5
• The Animal Naming Test is the only validated bedside test available to date 1

Management Based on West Haven Grade

Grade I (Covert HE)

• Treatment is not routinely recommended but may be considered if affecting daily functioning, employment, or public safety 4
• Non-absorbable disaccharides (lactulose) should be used if treatment is initiated 1

Grade II

• Lactulose is first-line treatment, titrated to achieve 2-3 soft stools per day 4, 6
• Identify and correct precipitating factors (infections, GI bleeding, constipation, dehydration, electrolyte disturbances) 4
• Rifaximin may be added, particularly for recurrent episodes 7

Grades III-IV

• Requires intensive care monitoring due to airway compromise risk 1, 4
• Lactulose administration (oral or via nasogastric tube if unable to take orally) 4, 6
• Rifaximin as add-on therapy 4, 7
• Glasgow Coma Scale assessment for monitoring 1
• Consider albumin dialysis, though impact on prognosis remains uncertain 1

Common Pitfalls to Avoid

• Do not rely on grade I West Haven criteria alone for diagnosis due to poor inter-rater reliability—use objective testing instead 1
• Do not use ammonia levels for diagnosis, staging, or monitoring—they do not add diagnostic value 4
• Do not confuse hepatic encephalopathy with other causes of altered mental status—always exclude alternative diagnoses 1, 4, 3
• Do not fail to identify precipitating factors—their identification and treatment is essential for successful management 1, 4
• Do not forget secondary prophylaxis after the first episode of overt HE 4

Enhanced Grading Tools

The Hepatic Encephalopathy Scoring Algorithm (HESA) was developed to provide more objective assessment by combining clinical indicators with simple neuropsychological tests. 2 The most effective indicators across grades include lack of verbal/eye/motor response (grade IV), somnolence and disorientation to place (grade III), and lethargy and disorientation to time (grade II). 2

Bispectral index monitoring has shown promise with specific cut-off values for each grade: 90.5 for minimal HE, 77.5 for grade I, 70.5 for grade II, 60.5 for grade III, and 50.5 for grade IV. 8 However, this remains primarily a research tool and is not part of standard clinical practice guidelines.