AI Summary Grade II hepatic encephalopathy is overt HE, and asterixis, a flapping tremor of the hands, is a hallmark sign of this grade.
Medically reviewed.
Grade II hepatic encephalopathy (HE) — moderate HE — is the third point on the West Haven scale doctors use to grade HE, a decline in brain function caused by the liver's inability to remove toxins from the blood. At grade II, the signs are no longer subtle. A person may be disoriented, unusually sleepy, or confused, and may have slurred speech and asterixis, a flapping tremor of the hands.
Grade II is overt HE, meaning the changes can be seen without special testing. HE is treatable and often reversible, especially when the person and the people around them recognize it early and act. Do not wait to see if it goes away. Call the liver team.
This page explains what grade II looks like, what to do right away, how it is diagnosed and treated, common triggers, and how to lower the chance of another episode.
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Where Grade II Fits
Doctors grade hepatic encephalopathy (HE) using the West Haven criteria, a bedside exam of mental status and movement. The scale runs from Grade 0, with no detectable symptoms, to Grade IV, coma. Grade II sits in the middle. It is the stage where asterixis, a flapping tremor of the hands, becomes a hallmark sign, often alongside disorientation and lethargy.
Grade II is overt HE, so a doctor can diagnose it from your history and a bedside exam. Covert HE, by contrast, causes subtle changes in attention and thinking that only special tests can detect.
Grade II is a warning, not a dead end. HE is treatable and often reversible, and most episodes are set off by a specific event, such as an infection or bleeding. Finding and treating that trigger often resolves the episode. Without care, HE can progress toward stupor or coma, so grade II deserves prompt attention.
If someone with liver disease becomes more confused, sleepy, or shaky than usual, act right away. Do not wait to see if it goes away.
Key Terms
A few terms come up often when talking about moderate hepatic encephalopathy.
Diagnosis and Treatment
Grade II HE is usually managed by your liver team. Care follows a few consistent priorities.
Overt HE is diagnosed mainly from your history, your mental state, and how you move. Doctors look for signs such as asterixis, confusion, slurred speech, lethargy, and disorientation. Blood tests and brain scans may be used to check for other causes. A blood ammonia level alone does not add to diagnosis, grading, or outlook in chronic liver disease.
Most HE episodes are set off by a specific event, such as a bacterial infection, gastrointestinal bleeding, constipation, or sedatives and diuretics. Finding and treating the trigger is a cornerstone of care, and it often resolves the episode.
Lactulose is the first choice for treating an episode of overt HE. It helps the gut clear ammonia-producing waste. Your care team sets the dose and adjusts it to your response. Common side effects include diarrhea, bloating, gas, nausea, and cramping.
Rifaximin is a prescription antibiotic that lowers ammonia-producing bacteria in the gut. It is added to lactulose for people whose HE comes back, and the combination lowers the risk of further episodes and hospital stays.
What Can Trigger It
Identifying and treating the trigger is a cornerstone of HE care. Resolving the underlying cause often leads to improvement.
Outlook and Prevention
Grade II HE is overt and needs attention, but it is often reversible once the trigger is treated.
HE is treatable and often reversible, especially when it is recognized early. Checking in with your team at the first sign of fogginess gives treatment the best chance to work.
Stay hydrated, but not too much. Avoid alcohol and sedating pills. Keep a regular sleep routine and eat consistent meals. Call your team quickly if you have a fever, bleeding, illness, or a new medication.
Visible reminders can help when the fog rolls in, such as a whiteboard with the date, pictures of loved ones, or a familiar object by your bed. Keep phones and emergency contacts within reach.
Overt HE occurs in about 10–14% of people when cirrhosis is diagnosed, and in 30–40% at some point during the course of cirrhosis. If HE comes back after treatment, ask your liver team about rifaximin and about whether a liver transplant evaluation is appropriate.
Nutrition Support
Nutrition plays a real role in preventing another HE episode. Malnutrition and muscle loss (sarcopenia) are independent risk factors for HE, so eating enough is part of treatment, not an afterthought.
Protein used to be restricted in HE. Experts now know that restriction is harmful. Talk with your liver team or a dietitian about targets that fit your body and your stage of liver disease.
Nutrition Targets Used Alongside Medical Treatment
Grade II hepatic encephalopathy is a moderate, overt stage of brain dysfunction caused by the liver's inability to clear toxins from the blood. It is the third point on the West Haven scale, after Grade 0 and Grade I. A person may be disoriented, confused, or unusually sleepy, may have slurred speech, and may have asterixis, a flapping tremor of the hands. Unlike covert HE, these signs can be seen without special testing. HE at this stage is treatable and often reversible.
The most recognizable sign is asterixis, a flapping movement of the hands when the arms are held out. It is not a true tremor. It comes from a brief loss of muscle tone. Other signs include disorientation, confusion, lethargy, and slurred speech. Family members may also notice forgetfulness, slower responses, trouble with simple tasks, or sleep that flips between night and day. Asterixis can occur in other conditions too, such as kidney failure, so doctors look at the full picture.
Call your liver team the same day. Do not wait to see if the confusion goes away. Tell them about any fever, bleeding, illness, or new medication. Drink enough fluid, plain if possible, and avoid alcohol and sedating pills. Stay where someone can see you, and do not drive or handle sharp tools. Go to the emergency room or call 911 if confusion gets worse or the person becomes hard to wake, because HE can progress to more severe grades.
Doctors diagnose overt HE mainly from your medical history, your mental state, and a bedside exam of thinking and movement. They look for signs such as asterixis, disorientation, confusion, slurred speech, and lethargy. Blood tests, liver function tests, and scans may be used to check for other causes and for triggers. A high blood ammonia level alone does not help diagnose, stage, or predict the outcome of HE in chronic liver disease, so doctors do not rely on it by itself.
Yes, HE is treatable and often reversible, especially when it is caught early. Most episodes are set off by a specific event, such as an infection, gastrointestinal bleeding, constipation, or sedating medicines and diuretics. Finding and treating that trigger often resolves the episode. Doctors also treat the episode itself with lactulose, the first-choice medicine for overt HE. Recovery time varies with the trigger and with how well your liver is working.
Lactulose is the first-choice medicine for an episode of overt HE. It works in the gut to help clear ammonia-producing waste, and your care team adjusts the amount to your response. If HE comes back, rifaximin, a prescription antibiotic that lowers ammonia-producing bacteria in the gut, is added to lactulose. The combination lowers the risk of further episodes and related hospital stays. Lactulose can cause diarrhea, bloating, gas, nausea, and cramping. Take these medicines exactly as your team directs, and do not skip doses.
Work with your liver team on the triggers you can control. Stay hydrated, but do not overdo fluids. Avoid alcohol, sedating pills, and skipping sleep. Call your team quickly if you have a fever, bleeding, illness, or a new medication. Keep a regular routine with consistent meals, and do not restrict protein, because restriction can be harmful. Eat small, frequent meals plus a late-evening snack. Keep a short daily note on sleep, clarity, and mood so you and your caregiver can spot a change early. If HE keeps coming back, ask your team about rifaximin and about a transplant evaluation.
Medical disclaimer: LiverDirectory provides educational information and a directory of providers. It does not provide medical advice, diagnosis, or treatment. Always consult a licensed physician regarding any medical condition.
