AI Summary Hepatic encephalopathy scores help doctors rate how advanced liver disease affects thinking and behavior. The West Haven Criteria grades severity from a bedside exam, while the HAST/HASA score estimates risk from blood tests and a short thinking test. Covert HE needs special testing, and overt HE starts at Grade II. Scores can change, so doctors repeat them. Treating triggers often ends an episode. Lactulose is the first choice, and rifaximin helps prevent return.
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Hepatic encephalopathy (HE) is a decline in brain function that can happen when advanced liver disease lets toxins build up in the blood. Hepatic encephalopathy scores give your care team a shared way to describe how mild or severe it is.
Some scores come from a bedside exam. Others combine blood results with short thinking tests. No single score tells the whole story, so your doctors read them together with your symptoms and history.
This page explains the main scores, how covert and overt HE differ, and how to prepare for a visit with a liver specialist.
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HE Severity Scoring Basics
Hepatic encephalopathy scores are tools doctors use to measure how much liver disease is affecting your brain. HE can look like forgetfulness, slowed thinking, sleep that flips between night and day, or confusion. In its most severe form, it can lead to coma.
HE is a continuum that doctors divide into levels. Doctors also classify every case by four factors: the underlying liver problem, the severity, the time course, and what triggered it. Scores answer the severity question. Most HE in people with cirrhosis is called type C.
Two scores on this site cover this group:
A score describes how you are doing at one point in time. HE can change quickly, so doctors repeat these checks to see whether treatment is working.
Scores in This Group
Each score answers a different question. Your doctor may use one or several.
A bedside grading scale. Your doctor checks orientation, attention, behavior, and movement, then assigns a grade. It needs no blood test and can be repeated during a hospital stay to track progress. Grade II and higher marks overt HE, and Grades III and IV are called brain failure.
A calculation that combines blood ammonia, bilirubin, INR, and creatinine with a short thinking test. A score under 10 suggests minimal risk, 10 to 20 suggests intermediate risk, and above 20 suggests high risk. Doctors may use it to watch risk over time, alongside the West Haven grade.
Subtle HE does not show up on a standard exam. It needs psychometric tests, such as the Psychometric Hepatic Encephalopathy Score (PHES), or a brain-wave test called electroencephalography (EEG). These tests measure attention, processing speed, and planning.
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Covert vs. Overt HE
HE is a continuum that doctors divide into levels.
| Level | West Haven grade | What doctors find | How it is found |
|---|---|---|---|
| Minimal HE | Below Grade I | Signs of brain dysfunction on testing only. No clinical signs, disorientation, or asterixis. | Psychometric or neurophysiological tests |
| Covert HE | Minimal HE and Grade I | Subtle problems with attention, speed, and planning that a standard exam can miss. | Tests such as PHES or EEG |
| Overt HE | Grade II and above | Disorientation or asterixis. May include confusion, slurred speech, or lethargy. | Bedside exam of mental status and movement |
| Brain failure | Grades III and IV | Severe HE, defined as Grade III or IV, or a Glasgow Coma Scale score below 8. | Hospital care, often in an intensive care unit |
Levels overlap, and HE can move between them. Your care team decides which level fits you.
Visit Preparation Tips
A score is most useful when you and your care team act on it early.
A short morning note about sleep, clarity, and mood can help. Rate the day as sharp, okay, fuzzy, or very confused. A slide toward fuzzy is an early warning to share with your team.
Most episodes follow a trigger, such as a bacterial infection, bleeding in the gut, constipation, or sedatives and diuretics. Treating the trigger often ends the episode. Call your team quickly if you have a fever, notice bleeding, or start a new medicine. Avoid alcohol and sedating pills.
Lactulose is the first choice for an episode of overt HE. Rifaximin is added to prevent return after a second episode. Your specialist sets the plan, so ask what each score means for your treatment. Read more on the [Hepatic Encephalopathy](/liver-therapies/liver-disease-complication-management/hepatic-encephalopathy) page.
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If confusion appears, stay where someone can see you. Do not drive or handle sharp tools. Keep your phone and emergency contacts within reach, and tell a trusted person to call your liver team.
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Common Questions
They are tools doctors use to rate how much liver disease is affecting your thinking and behavior. Hepatic encephalopathy (HE) can range from subtle changes in attention to confusion and, in its most severe form, coma. A score gives your care team a shared way to describe where you are on that range. The West Haven Criteria grades severity from a bedside exam. The HAST/HASA score estimates risk from blood tests and a short thinking test. Your doctor reads these scores together with your symptoms and history, because no single score tells the whole story.
The West Haven Criteria is the most common grading scale. It runs from Grade 0, with no detectable symptoms, to Grade IV, which is coma. Your doctor checks orientation, attention, behavior, and movement, then assigns a grade. No blood test is needed. Overt HE begins at Grade II, when a person becomes disoriented or has asterixis, a flapping movement of the hands. Grades III and IV are called brain failure and need hospital care, often in an intensive care unit. Because the exam is quick, doctors can repeat it during a hospital stay to track progress.
No. A high blood ammonia level alone does not add diagnostic, staging, or prognostic value in chronic liver disease. A result can look high in someone without HE, so the number cannot stand in for an exam. Doctors rely on your symptoms and a bedside exam instead. They may add thinking tests when they suspect subtle changes. Ammonia is one input into the HAST/HASA score, but it is combined with bilirubin, INR, creatinine, and a thinking test rather than read on its own.
Covert HE is a form of HE that causes subtle changes in attention, processing speed, and planning. These changes can be easy to miss because a standard exam may look normal and you may not feel confused. Finding it takes psychometric tests, such as the Psychometric Hepatic Encephalopathy Score (PHES), or a brain-wave test called electroencephalography (EEG). Finding it early matters because covert HE predicts overt HE, more hospital stays, and shorter survival. If you notice forgetfulness, slowed thinking, or sleep that flips between night and day, tell your care team.
Yes. A score describes how you are doing at one point in time, and HE can change quickly. A trigger such as an infection, bleeding in the gut, constipation, or a sedating medicine can move you to a higher level. Doctors repeat scores to see whether treatment is working and whether the condition is getting better or worse. Treating the trigger often ends an episode. You can help by keeping a short daily note about sleep, clarity, and mood, and by calling your team quickly if you feel more fuzzy or confused than the day before.
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.
