{"id":2315,"date":"2017-01-30T14:52:07","date_gmt":"2017-01-30T14:52:07","guid":{"rendered":"https:\/\/medicalcriteria.com\/web\/hasshep\/"},"modified":"2026-03-20T19:05:21","modified_gmt":"2026-03-20T19:05:21","slug":"hasshep","status":"publish","type":"post","link":"https:\/\/medicalcriteria.com\/web\/hasshep\/","title":{"rendered":"Criteria for Grading Hepatic Encephalopathy"},"content":{"rendered":"<div class=\"99c380e4b4a7b96c35d7ddf7dcb434e8\" data-index=\"1\" style=\"float: none; margin:0px 0 0px 0; text-align:center;\">\n<script async src=\"https:\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js\"><\/script>\r\n<!-- MC 2019- Horizontal -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-client=\"ca-pub-0127150553352455\"\r\n     data-ad-slot=\"3806776041\"\r\n     data-ad-format=\"auto\"\r\n     data-full-width-responsive=\"true\"><\/ins>\r\n<script>\r\n     (adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script>\n<\/div>\n<p>Grading of hepatic encephalopathy\u00a0categorizes it in clinical stages of stepwise worsening.\u00a0The description of each grade varies somewhat\u00a0in the literature, but differences between\u00a0adjacent grades are clear enough to be helpful in\u00a0clinical practice, although neurologic descriptors\u00a0are sparse. One study showed that for patients\u00a0who become comatose, the Full Outline of\u00a0Unresponsiveness (FOUR) score is more discriminating\u00a0than the West Haven grading system\u00a0because it includes brain-stem and respiration\u00a0assessment, which are not further differentiated\u00a0in the West Haven system.<br \/>\n<!--more--><\/p>\n<p><b>West Haven Criteria for Grading Hepatic Encephalopathy<\/b><\/p>\n<table style=\"border-collapse: collapse; width: 100%;\" border=\"1\">\n<tbody>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\"><b>Grade<\/b><\/td>\n<td width=\"382\"><b>Features<\/b><\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\">0<\/td>\n<td width=\"382\">No abnormalities detected<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\">1<\/td>\n<td width=\"382\">Unawareness (mild), euphoria or\u00a0anxiety, shortened attention span,\u00a0impairment of calculation ability,\u00a0lethargy or apathy<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\">2<\/td>\n<td width=\"382\">Disorientation to time, obvious personality change, inappropriate behaviour<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\">3<\/td>\n<td width=\"382\">Somnolence to stupor, responsiveness to stimuli, confusion, gross disorientation, bizarre behaviour<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"52\">4<\/td>\n<td width=\"382\">Coma<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p><b>FOUR Score Criteria for Grading Hepatic Encephalopathy<\/b><\/p>\n<table style=\"border-collapse: collapse; width: 100%;\" border=\"1\">\n<tbody>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\"><b>Score<\/b><\/td>\n<td width=\"115\"><b>Eye Response<\/b><\/td>\n<td width=\"115\"><b>Motor Response<\/b><\/td>\n<td width=\"115\"><b>Brain-Stem Reflex<\/b><\/td>\n<td width=\"114\"><b>Respiration<\/b><\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\">4<\/td>\n<td width=\"115\">Eyelids open or manually\u00a0opened; tracking or\u00a0blinking on command<\/td>\n<td width=\"115\">Thumbs up, fist, or peace\u00a0sign on command<\/td>\n<td width=\"115\">Pupillary and corneal\u00a0reflexes present<\/td>\n<td width=\"114\">Not intubated, regular breathing<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\">3<\/td>\n<td width=\"115\">Eyelids open but no tracking<\/td>\n<td width=\"115\">Localized response to pain<\/td>\n<td width=\"115\">One pupil wide and fixed<\/td>\n<td width=\"114\">Not intubated, Cheyne\u2013Stokes\u00a0breathing<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\">2<\/td>\n<td width=\"115\">Eyelids closed but open\u00a0to loud voice<\/td>\n<td width=\"115\">Flexion response to pain<\/td>\n<td width=\"115\">Pupillary or corneal\u00a0responses absent<\/td>\n<td width=\"114\">Not intubated, irregular breathing<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\">1<\/td>\n<td width=\"115\">Eyelids closed but open\u00a0to pain<\/td>\n<td width=\"115\">Extension response to pain<\/td>\n<td width=\"115\">Pupillary and corneal\u00a0responses absent<\/td>\n<td width=\"114\">Breathing above ventilator rate<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"53\">0<\/td>\n<td width=\"115\">Eyelids remain closed\u00a0to pain<\/td>\n<td width=\"115\">No response to pain, or\u00a0generalized myoclonus\u00a0status<\/td>\n<td width=\"115\">Pupillary, corneal, and\u00a0cough reflexes absent<\/td>\n<td width=\"114\">Breathing at ventilator rate or apnea<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p><b>Comparison of West Haven and FOUR Score Criteria for Grading Hepatic Encephalopathy<\/b><\/p>\n<table style=\"border-collapse: collapse; width: 100%;\" border=\"1\">\n<tbody>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\"><b>West Haven<\/b><\/td>\n<td style=\"text-align: center;\" width=\"132\"><b>FOUR Score<\/b><\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\">0<\/td>\n<td style=\"text-align: center;\" width=\"132\">4<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\">1<\/td>\n<td style=\"text-align: center;\" width=\"132\">3<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\">2<\/td>\n<td style=\"text-align: center;\" width=\"132\">2<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\">3<\/td>\n<td style=\"text-align: center;\" width=\"132\">1<\/td>\n<\/tr>\n<tr valign=\"TOP\">\n<td style=\"text-align: center;\" width=\"132\">4<\/td>\n<td style=\"text-align: center;\" width=\"132\">0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p><b>References:<\/b><\/p>\n<ol>\n<li>Wijdicks EF. Hepatic Encephalopathy. N Engl J Med. 2016 Oct 27;375(17):1660-1670.\u00a0<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27783916\/\" target=\"_blank\" rel=\"noopener noreferrer\">[Medline]<\/a><\/li>\n<li>Kandiah PA, Kumar G. Hepatic Encephalopathy-the Old and the New. Crit Care Clin. 2016 Jul;32(3):311-29.\u00a0<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27339673\/\" target=\"_blank\" rel=\"noopener noreferrer\">[Medline]<\/a><\/li>\n<li>Bajaj JS, Jakab SS, Jesudian AB, Rahimi RS, Duarte-Rojo A, Chen PH, Wong RJ, Tapper EB, Tandon P. ACG Clinical Guideline: Hepatic Encephalopathy. Am J Gastroenterol. 2026 Mar 1;121(3):588-618. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/41773757\/\" target=\"_blank\" rel=\"noopener\">[Medline]<\/a><\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p>Created: Jan 30, 2017.<br \/>\nUp-date: Mar 20, 2026.<\/p>\n\n<div style=\"font-size: 0px; height: 0px; line-height: 0px; margin: 0; padding: 0; clear: both;\"><\/div>","protected":false},"excerpt":{"rendered":"<p>Sorry, this entry is only available in Espa\u00f1ol.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"no","_lmt_disable":"no","_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[53],"tags":[16,15,652,651,650,227,621,649,648,647,450,653],"class_list":["post-2315","post","type-post","status-publish","format-standard","hentry","category-gastroenterology","tag-criteria","tag-criterios","tag-encefalopatia","tag-encephalopathy","tag-four","tag-grading","tag-graduacion","tag-haven","tag-hepatic","tag-hepatica","tag-score","tag-west"],"modified_by":"Guillermo Firman","_links":{"self":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/2315","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/comments?post=2315"}],"version-history":[{"count":4,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/2315\/revisions"}],"predecessor-version":[{"id":10722,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/2315\/revisions\/10722"}],"wp:attachment":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/media?parent=2315"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/categories?post=2315"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/tags?post=2315"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}