What is the recommended grading system for a patient with decompensated cirrhosis and suspected Hepatic Encephalopathy (HE)?

Grading of Hepatic Encephalopathy in Decompensated Cirrhosis

Use the West Haven Criteria as your primary grading system, supplemented by the modern ISHEN classification that divides patients into covert HE (minimal HE plus Grade I) versus overt HE (Grade II or higher), with the critical clinical threshold being the presence of disorientation to time. 1

West Haven Criteria: The Gold Standard

The West Haven Criteria remain the most widely accepted grading system despite significant inter-rater variability, particularly between lower grades 1, 2:

Grade 0 (Unimpaired)

• No clinical, neuropsychometric, or neurophysiological abnormalities 1
• Normal cognitive function on all testing modalities 1

Grade I (Covert HE)

• Subtle behavioral changes, mild confusion, or sleep disturbance 1
• No disorientation and no asterixis present 1
• Extremely high inter-observer variability in identification 1
• Often requires specialized neuropsychometric testing for detection 3

Grade II (Overt HE - Threshold for Treatment)

• Lethargy or apathy with disorientation to time 1
• Possible asterixis present 1
• Good inter-rater reproducibility when using operative definitions emphasizing disorientation 1
• Requires therapeutic intervention 1
• Most reproducible clinical marker: disorientation to time (at least three of the following wrong: day of the month, day of the week, month, season, or year) 3

Grade III (Overt HE - ICU Level)

• Somnolence to semi-stupor 1
• Responsiveness to verbal stimuli 1
• Confusion and gross disorientation 1
• Disoriented also in space (at least three of the following wrongly reported: country, state/region, city, or place) 3

Grade IV (Overt HE - Coma)

• Coma and unresponsiveness to verbal or noxious stimuli 1, 3
• Does not respond even to painful stimuli 3

Modern ISHEN Classification Framework

The International Society for Hepatic Encephalopathy and Nitrogen Metabolism recommends a simplified two-category system that is clinically more practical 3, 1:

Covert Hepatic Encephalopathy

• Encompasses minimal HE plus Grade I West Haven criteria 1, 3
• Defined by absence of disorientation AND absence of asterixis 1
• Patients appear clinically normal but demonstrate neuropsychometric/neurophysiological abnormalities 1
• Generally not treated in routine clinical practice 1
• Prevalence ranges from 22-78% in cirrhotic patients, with 25.6% in Korean studies 3

Overt Hepatic Encephalopathy

• Encompasses West Haven Grade II or higher 1, 3
• Characterized by evident clinical abnormalities with changes in mental status 1
• Requires medical intervention and possible hospitalization 1
• Disorientation and flapping tremor (asterixis) are characteristic 3

SONIC Classification for Prognostic Stratification

This provides additional clinical context beyond simple grading 1:

Stable Impairment

• Covert or overt HE with minimal day-to-day fluctuation 1
• Majority remain independent in daily activities 1

Unstable Impairment (Episodic HE)

• Previously stable patients who develop acute deterioration over hours to days 1
• Progressing from acute confusional syndrome to coma 1
• Requires medical attention and hospitalization 1

Critical Clinical Pitfalls to Avoid

Asterixis Automatically Excludes Covert HE

Patients with flapping tremor, even without disorientation, should be classified as having overt HE 1. This is a common error where clinicians may underestimate severity.

Disorientation to Time is the Key Differentiator

Use disorientation to time as the primary differentiator between covert and overt HE rather than subjective behavioral changes 1. This provides the most reproducible clinical marker with good inter-rater reliability 1, 4.

Inter-Rater Variability is Highest at Lower Grades

The categorical approach has arbitrary boundaries with high inter-rater variability, particularly between Grades 0, minimal, and I 3, 1. When in doubt at these lower grades, consider using two or more validated neuropsychometric tests 3.

Don't Rely on Glasgow Coma Scale for Lower Grades

While the Glasgow Coma Scale differs among the four stages of West Haven Criteria, the differences between grades I and II are small and not clinically useful 4. The FOUR score (Full Outline of UnResponsiveness) may be superior for detecting and quantifying overt HE, especially by non-hepatologists 5.

Practical Clinical Algorithm

For bedside assessment in decompensated cirrhosis:

1. Check for disorientation to time (ask day of week, date, month, season, year) - if 3+ wrong → Grade II or higher 3, 1
2. Check for asterixis - if present → Overt HE (at minimum Grade II) 1
3. If both absent but subtle changes present → Consider Grade I (covert HE), may need neuropsychometric testing 1, 3
4. If somnolent but arousable to verbal stimuli → Grade III 1
5. If comatose/unresponsive → Grade IV 1

The most effective clinical indicators across grades include: lack of verbal, eye, and motor response (Grade IV); somnolence and disorientation to place (Grade III); and lethargy and disorientation to time (Grade II) 4.