Unifying Concepts

Criteria for Grading Hepatic Encephalopathy

Grading of hepatic encephalopathy categorizes it in clinical stages of stepwise worsening. The description of each grade varies somewhat in the literature, but differences between adjacent grades are clear enough to be helpful in clinical practice, although neurologic descriptors are sparse. One study showed that for patients who become comatose, the Full Outline of Unresponsiveness (FOUR) score is more discriminating than the West Haven grading system because it includes brain-stem and respiration assessment, which are not further differentiated in the West Haven system.

West Haven Criteria for Grading Hepatic Encephalopathy

Grade Features
0 No abnormalities detected
1 Unawareness (mild), euphoria or anxiety, shortened attention span, impairment of calculation ability, lethargy or apathy
2 Disorientation to time, obvious personality change, inappropriate behaviour
3 Somnolence to stupor, responsiveness to stimuli, confusion, gross disorientation, bizarre behaviour
4 Coma


FOUR Score Criteria for Grading Hepatic Encephalopathy

Score Eye Response Motor Response Brain-Stem Reflex Respiration
4 Eyelids open or manually opened; tracking or blinking on command Thumbs up, fist, or peace sign on command Pupillary and corneal reflexes present Not intubated, regular breathing
3 Eyelids open but no tracking Localized response to pain One pupil wide and fixed Not intubated, Cheyne–Stokes breathing
2 Eyelids closed but open to loud voice Flexion response to pain Pupillary or corneal responses absent Not intubated, irregular breathing
1 Eyelids closed but open to pain Extension response to pain Pupillary and corneal responses absent Breathing above ventilator rate
0 Eyelids remain closed to pain No response to pain, or generalized myoclonus status Pupillary, corneal, and cough reflexes absent Breathing at ventilator rate or apnea


Comparison of West Haven and FOUR Score Criteria for Grading Hepatic Encephalopathy

West Haven FOUR Score
0 4
1 3
2 2
3 1
4 0



  1. Wijdicks EF. Hepatic Encephalopathy. N Engl J Med. 2016 Oct 27;375(17):1660-1670. [Medline]
  2. Kandiah PA, Kumar G. Hepatic Encephalopathy-the Old and the New. Crit Care Clin. 2016 Jul;32(3):311-29. [Medline]


Created: Jan 30, 2017.

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