You Have Advanced Liver Disease
You have cirrhosis, chronic hepatitis, or another advanced liver condition, and your doctor wants a standard way to describe any changes in your thinking or behavior.
AI Summary The West Haven Criteria grades hepatic encephalopathy (HE), a decline in brain function from advanced liver disease, from Grade 0 to Grade IV (coma). Doctors assign the grade with a bedside mental status and neurological exam, not a blood test. Grades 0–I are covert; Grade II and above is overt. Infections, bleeding, constipation, and dehydration commonly trigger episodes. Treatment includes lactulose, sometimes rifaximin, and trigger care; Grades III–IV usually need hospital care. Recurrent overt HE may prompt transplant evaluation.
Source: www.liverdirectory.com
West Haven Criteria
Medically Reviewed.
The West Haven Criteria (also called the West Haven grading scale) is a clinical tool doctors use to grade the severity of hepatic encephalopathy (HE), a decline in brain function caused by advanced liver disease. It ranges from Grade 0, with no detectable symptoms, to Grade IV, coma.
Unlike a blood-based score, the West Haven Criteria is based entirely on a bedside mental status and neurological exam — no lab work or imaging is required to assign a grade, though your doctor may still order blood tests to look for what triggered an episode.
This page explains what each grade means, how covert and overt HE differ, common triggers, how your grade guides treatment, and how nutrition supports HE care alongside medication.
On this page
Liver Health AI Assistant
Ask Aimy
Turn confusion into a better next question.
Aimy answers from LiverDirectory’s reviewed health information — helping patients make sense of liver-health terms, prepare for specialist visits, and explore what to look up next.
West Haven Criteria at a Glance
- The West Haven Criteria grades hepatic encephalopathy from Grade 0 (no symptoms) to Grade IV (coma) using a bedside mental status and neurological exam — no blood test is required to assign a grade.
- Overt HE — Grade II and above — is defined by the onset of disorientation or asterixis, a flapping hand tremor.
- An estimated 30% to 40% of people with cirrhosis develop overt HE at some point.
- Grade III and Grade IV HE are sometimes called "brain failure" and typically require hospital or ICU-level care.
Hepatic Encephalopathy Scale Basics
What Is the West Haven Criteria?
The West Haven Criteria (sometimes called the West Haven grading scale) is a clinical scale doctors use to describe how severe a person's hepatic encephalopathy (HE) is. HE is a decline in brain function that happens when a damaged liver can no longer clear toxins, mainly ammonia, from the blood.
The scale runs from Grade 0, where no symptoms are noticeable, to Grade IV, coma. Doctors assign a grade based on a bedside mental status and neurological exam — checking orientation, attention, behavior, and for asterixis, a flapping tremor of the hands. No blood draw or imaging is needed to grade HE this way, although your care team may still order blood work to help find what triggered the episode.
Because HE can change quickly, doctors often repeat the West Haven assessment over hours or days rather than relying on a single grade, so they can track whether treatment is working.
When Doctors Grade HE
Why Your Doctor Might Grade You With the West Haven Criteria
Doctors use the West Haven Criteria in several situations.
You or Your Family Notice Confusion
You've had memory lapses, disorientation, unusual sleepiness, or a reversed sleep-wake pattern, and your doctor needs to grade how severe it is.
You're Hospitalized for a Liver Complication
You're admitted for a complication such as gastrointestinal bleeding or infection, and your care team is checking for hepatic encephalopathy as a possible trigger or result.
Your Treatment Is Being Monitored
You're on lactulose or rifaximin for hepatic encephalopathy, and your doctor re-checks your West Haven grade to see whether treatment is working.
HE Severity Grading Scale
The Five West Haven Grades
Doctors assign a grade after a bedside mental status and neurological exam. Earlier grades are usually fully reversible once the underlying trigger is treated.
| Grade | Common name | Key signs | Status |
|---|---|---|---|
| Grade 0 | No detectable changes (minimal HE) | No obvious symptoms; subtle attention or reaction-time deficits may only show up on specialized psychometric testing. | Covert |
| Grade I | Mild HE | Trivial lack of awareness, shortened attention span, mild anxiety or euphoria, and a reversed sleep-wake pattern. | Covert |
| Grade II | Moderate HE | Lethargy, disorientation to time, obvious personality change, and asterixis — a flapping tremor of the outstretched hands. | Overt |
| Grade III | Severe HE | Marked confusion, gross disorientation to time and place, somnolence but still arousable, and often more pronounced asterixis. | Overt |
| Grade IV | Coma | Unresponsive to voice or pain, with no purposeful response; airway protection and intensive care are usually needed. | Overt |
Grades III and IV are medical emergencies. If someone with liver disease becomes very hard to wake or unresponsive, seek emergency care right away.
Covert and Overt Symptoms
Covert HE vs. Overt HE
The West Haven Criteria splits hepatic encephalopathy into two broad categories.
Covert HE (Grade 0–I)
Covert HE covers Grade 0 (minimal HE) and Grade I. It has no obvious clinical signs — disorientation and asterixis are absent — so it usually requires formal psychometric or neurophysiological testing to detect. Despite being subtle, covert HE predicts a higher chance of developing overt HE later, more hospitalizations, and reduced survival, so it is not just a minor finding.
Overt HE (Grade II–IV)
Overt HE begins at Grade II, defined by the onset of disorientation or asterixis. It's diagnosed clinically, at the bedside, without needing a lab test to confirm it. Cumulatively, overt HE develops at some point in an estimated 30% to 40% of people with cirrhosis.
Why Ammonia Levels Aren't Used to Grade HE
Increased blood ammonia is common in HE, but a single ammonia level does not reliably diagnose, stage, or predict outcomes for hepatic encephalopathy in people with chronic liver disease. A normal ammonia level makes HE less likely, but the West Haven grade itself is based on the clinical exam, not the lab number.
Treatment by HE Grade
How Your West Haven Grade Guides Treatment
What Usually Triggers an Episode
Most HE episodes are triggered by a specific event rather than liver disease alone. The most common triggers are bacterial infections (present in over half of patients at the time HE appears), gastrointestinal bleeding, constipation, dehydration, and sedative or diuretic medications. Finding and treating the trigger is a cornerstone of care, because resolving it often resolves the HE episode as well.
Grade I–II: Outpatient or Short-Stay Treatment
Grade I and II HE are usually managed with lactulose, a non-absorbable sugar that reduces ammonia in the gut, sometimes combined with rifaximin to lower ammonia-producing gut bacteria. Your care team will also look for and treat the trigger — for example, antibiotics for an infection or fluids for dehydration.
Grade III–IV: Hospital and ICU-Level Care
Grade III HE ("brain failure" when combined with Grade IV) usually calls for hospital admission, and Grade III or higher may need ICU-level monitoring for airway protection, since confused or very sleepy patients are at risk of inhaling food or fluid into their lungs. Grade IV, coma, requires intubation and mechanical ventilation to protect the airway while the underlying cause is treated.
When HE Affects Transplant Planning
Recurrent or persistent overt HE that doesn't respond to medical therapy is associated with a poor outlook and is recognized as a reason to consider liver transplant evaluation, even when a person's MELD score alone doesn't fully reflect how sick they are.
Find a Liver Specialist Who Treats Hepatic Encephalopathy
Explore Liver Diet
A balanced, liver-friendly diet supports your liver, helps manage weight and blood sugar, and lowers the risk of other health problems during long-term follow-up.
Explore Liver DietSupport Your Diet Alongside Follow-Up Care
The Amsety Bar is a liver-friendly snack or meal replacement that can make it easier to eat well on busy days.
Shop Amsety Bars
Common Questions
Answers to Common West Haven Criteria Questions
Is the West Haven Criteria a blood test?
No. The West Haven Criteria is based entirely on a bedside mental status and neurological exam — checking orientation, attention, behavior, and for asterixis, a flapping hand tremor. Your doctor may still order blood tests, such as an ammonia level, to help find what triggered an episode, but the grade itself does not come from a lab result.
What's the difference between covert and overt hepatic encephalopathy?
Covert HE (Grade 0–I) has no obvious clinical signs and usually needs formal psychometric or neurophysiological testing to detect. Overt HE (Grade II and above) is diagnosed at the bedside, without special testing, once disorientation or asterixis appears.
Can hepatic encephalopathy be reversed?
Often, yes. Many episodes — especially Grade I through III — improve once the trigger, such as an infection, gastrointestinal bleeding, constipation, or dehydration, is identified and treated, combined with lactulose therapy. Grade IV, coma, is a medical emergency that needs immediate hospital-level care.
How often is the West Haven grade reassessed?
Because hepatic encephalopathy can change within hours, doctors often repeat the bedside exam multiple times during a hospital stay or clinic visit. Reassessing the grade helps the care team track whether a person is improving or worsening and whether treatment is working.
Does a West Haven grade affect liver transplant priority?
It can. Recurrent or persistent overt hepatic encephalopathy that doesn't respond to medical therapy is linked to a poorer outlook and is recognized as a reason to consider liver transplant evaluation, even when a person's MELD score alone doesn't fully capture how sick they are. Your transplant team weighs your West Haven grade alongside your MELD score and other findings.
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.