Grade 0 — Covert / Minimal HE (CHE/MHE)

No clinical evidence of altered mental status, confusion, or asterixisNormal mental status on bedside assessment.Abnormal psychometric/neuropsychological testing if performedPHES < −4, or EncephalApp Stroop ≥ 190 seconds in age-adjusted norms.

Grade 1 — Mild HE

Sleep-wake reversal or sleep disturbance (insomnia, hypersomnia)Day-night inversion or significant sleep disruption.Shortened attention span or difficulty with complex tasksPatient reports difficulty concentrating, forgetfulness, or mental fog.Subtle personality change or mild mood disturbanceMild euphoria, anxiety, or reduced motivation not explained by psychiatric history.Asterixis may or may not be present (Grade 1 is borderline)Flapping tremor of outstretched wrists. Often absent in Grade 1, present in Grade 2.

Grade 2 — Moderate / Overt HE ← Hospitalize

Obvious lethargy, drowsiness, or slowed responsesPatient slow to wake, drowsy, or sleeping more than usual but arousable.Disorientation to time (date, day, month) ± placeCannot correctly state the date, day of week, or is confused about location.Obvious personality change or inappropriate behaviorAgitation, disinhibition, emotional lability.Asterixis presentBilateral flapping tremor of outstretched hands with wrists dorsiflexed.

Grade 3 — Severe / Overt HE ← ICU Consider

Stuporous but arousable to verbal stimulationPatient arousable but immediately returns to sleep/stupor.Disoriented to person AND time AND placeSevere global disorientation.Gross behavioral/cognitive abnormality (disorganized speech, confusion)Incoherent, bizarre, or disorganized speech.Primitive reflexes may be presentHyperreflexia, clonus, Babinski may develop.

Grade 4 — Coma ← ICU/Intubation Indicated

Unresponsive to all stimulation (coma)No purposeful response to painful stimuli. GCS typically 3–6.Asterixis absent (cannot be elicited in coma)Cannot test asterixis in unresponsive patient.

West Haven Criteria for Hepatic Encephalopathy Grade

West Haven Criteria for Hepatic Encephalopathy Grade