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Grades of hepatic encephalopathy, from mild changes to coma | CION Cancer Clinics
Hepatic encephalopathy is graded from 1, mild changes in mood, sleep and attention, to 4, coma. The grade tells doctors how strongly a struggling liver is affecting the brain. This confusion is usually treatable and often reverses once its trigger is found. This page explains what each grade looks like at home, what the doctors will do, and when you must go to hospital the same day. At CION Cancer Clinics, our team supports patients and families through symptoms, follow-up and life during and after treatment.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed October 2026, next review due October 2027
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On this page
- What do grades 1, 2, 3 and 4 of hepatic encephalopathy mean?
- What does each grade look like at home?
- What will the doctors do once the grade is known?
- Words you may see on the discharge summary
- What families often believe about this confusion
- What this page cannot tell you
- Common questions about the grades of encephalopathy
The short answer
What do grades 1, 2, 3 and 4 of hepatic encephalopathy mean?
The grades describe how strongly a struggling liver is affecting the brain. Grade 1 is mild: small changes in mood, sleep and attention that family notice before doctors do. Grade 4 is coma. Grades 2 and 3 sit in between, from drowsy and muddled to barely rousable.
Hepatic encephalopathy means brain changes caused by liver disease. When the liver cannot clear toxins from the blood, such as ammonia made in the gut, those toxins reach the brain and slow it down. It happens in people with cirrhosis, and in people whose liver cancer has taken over enough of the liver.
The most important thing families are not told
This kind of confusion is usually treatable and often reverses. A person who seemed to be "going mad" or "becoming stubborn" can be back to themselves within days once the trigger is found and treated. It is a medical problem in the liver and the gut. It is not madness, a personality change or a psychiatric illness, and it needs the liver team, not a mental health hospital.
Any new confusion or drowsiness in someone with liver disease or liver cancer needs a doctor the same day, whatever grade you think it is.Grade by grade
What does each grade look like at home?
Doctors use a scale called the West Haven criteria. Here is what each step tends to look like to the family living with it.
Grade 1: mild
The person is awake and talking, but something is off. They are short-tempered, anxious or unusually flat. Sleep turns upside down. Simple sums and handwriting get harder.
Families often say
- "He is not himself"
- "She keeps losing her train of thought"
- "He sleeps all day and roams at night"
Grade 2: moderate
Clearly drowsy and slow. The person may not know the day or the date. Behaviour can be odd or out of character. The hands often show a flapping movement when held out straight.
This is often when families take the person to the wrong specialist.Grade 3: severe
Very sleepy but can still be woken. When awake, the person is badly confused, may not know where they are, and may speak in fragments or be agitated. They cannot look after themselves safely.
Grade 4: coma
The person cannot be woken, even by a firm voice or touch. This is a medical emergency that needs hospital care straight away.
Not sure whether this applies to you?
Ask an oncologist
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Go to hospital today
If someone with liver disease or liver cancer becomes newly confused, unusually drowsy, hard to wake or behaves strangely, take them to hospital today. Do not wait to see whether it passes overnight. Go straight away, by ambulance if needed, if they cannot be woken, have a fit, vomit blood, pass black stools or have a fever. Tell the doctors about the liver disease and bring the list of medicines.
In hospital
What will the doctors do once the grade is known?
Check it really is the liver
Low sugar, an infection, a stroke, low salt and some medicines can all cause confusion too. Blood tests and an examination rule these out first, and a brain scan is done if needed.
Look for the trigger
Most episodes have a cause: constipation, an infection, bleeding in the gut, dehydration, low salt or sleeping tablets. Finding it is the single most useful step, because treating it often turns the confusion around.
Clear the gut
Lactulose, a syrup that softens stools and removes toxins through the bowel, is the usual first treatment. Rifaximin, an antibiotic that stays in the gut, may be added to stop episodes coming back.
Protect the airway at higher grades
At grade 3 or 4, the person may need close monitoring or intensive care to keep them safe while the treatment works.
Plan to prevent the next one
Before going home, the family should know the daily lactulose routine, the warning signs and when to come back.
On the notes
Words you may see on the discharge summary
- HE
- Short for hepatic encephalopathy: brain changes caused by the liver not clearing toxins.
- West Haven grade
- The usual scale for how severe an episode is, from grade 1 (mild) to grade 4 (coma).
- Covert or minimal HE
- Changes too subtle to see in conversation, found only with special attention or memory tests. It still affects driving and work.
- Overt HE
- Changes that anyone can see, roughly grade 2 and above.
- Asterixis
- The flapping movement of the hands when the arms are held out with the wrists bent back.
- Precipitating factor
- The trigger that set off this episode, such as an infection or constipation.
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Commonly believed
What families often believe about this confusion
"He has gone mad. We need a psychiatrist."
The confusion comes from toxins the liver cannot clear. A liver doctor or the cancer team treats it. Calming medicines and sleeping tablets can make it much worse.
"Once it reaches grade 3 or 4, there is no coming back."
Many people wake up and return to their usual selves after even a severe episode, once the trigger is treated. Each person is different, and the team will tell you what they expect for your relative.
"She should stop eating dal and eggs to protect her brain."
The old advice to cut protein has changed. Most people with cirrhosis need enough protein to keep their muscles, which also help clear ammonia. Read why protein is no longer cut.
"Too many loose motions on lactulose means we should stop it."
Lactulose is meant to give soft, regular stools. If there is watery diarrhoea, ask the team how to adjust it. Stopping it on your own is one of the commonest reasons an episode returns.
Being straight with you
What this page cannot tell you
It cannot grade your relative for you. Grading needs a doctor who examines the person, checks how alert they are and rules out other causes of confusion. Families are very good at noticing that something has changed, so trust that instinct and get help early.
It cannot tell you what the episode means for the cancer
In someone with liver cancer, encephalopathy may come from a simple trigger that is easy to fix, or it may be a sign that the liver as a whole is struggling. These two situations lead to very different treatment conversations. Only the team looking after your relative can tell you which one you are in. Ask them directly.
Who this page does not apply to
Confusion in someone with a healthy liver has other causes, and this grading does not apply. In a person with cancer that has spread to the brain, or who is on strong painkillers, the confusion may come from somewhere else. Read how doctors tell encephalopathy from dementia or depression.
At CION, the oncology team works with hepatologists through partner hospitals, and can explain the plan to the whole family together.Questions we are asked
Common questions about the grades of encephalopathy
Can hepatic encephalopathy be reversed?
Often, yes. Once the trigger is treated and the gut is cleared with lactulose, many people return to how they were before the episode. How fully they recover depends on how well the liver is working underneath, which the treating team can explain for your relative.
Can the grade change from day to day?
Yes. A person can move from grade 1 to grade 3 within a day if a trigger such as an infection or bleeding takes hold. They can also improve quickly with treatment. That is why any change, better or worse, should be reported to the team.
Is grade 1 serious enough to see a doctor?
Yes. Grade 1 is the stage where a simple fix, such as treating constipation, works best. New confusion or drowsiness should be seen the same day. Waiting for it to get worse makes the episode harder to treat and the person less safe at home.
What is the flapping of the hands?
It is called asterixis. When the arms are held out with the wrists bent back, the hands drop and jerk back in a flapping movement. It is a common sign from grade 2 onwards. Read more in flapping hands and other signs.
Does encephalopathy mean the cancer has spread to the brain?
No. Encephalopathy comes from toxins in the blood, not from cancer in the brain. Liver cancer rarely spreads to the brain. If doctors are unsure, they may arrange a brain scan to check for other causes.
Can my relative be cared for at home?
Mild episodes are sometimes managed at home once the doctor has seen the person and the trigger is clear. Grades 3 and 4 always need hospital. At home, someone should stay with them, keep them away from the stove and the road, and give the medicines as prescribed.
Can cancer treatment continue after an episode?
Sometimes. The oncologist will look at how quickly the person recovered and what the liver blood tests show. A single episode with a clear trigger is viewed differently from repeated episodes. The team will discuss whether treatment should continue, pause or change.
Who should we call if the confusion returns?
If it is sudden or the person is hard to wake, go to the nearest hospital today. For milder changes, call the team treating the liver or the cancer the same day. The CION helpline can help you reach the right person if you are not sure who to call.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
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Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
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Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
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Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
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Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
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Sources
- Liver UK (formerly British Liver Trust) — Hepatic encephalopathy (HE)
- Merck Manual Consumer Version — Hepatic Encephalopathy
- MedlinePlus — Loss of brain function - liver disease
- NIDDK — Symptoms & Causes of Cirrhosis - NIDDK
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Hepatic encephalopathy: why the liver affects the brainThe cause behind the confusion, explained simplyWhat triggers an episodeThe common triggers you can watch for at homeWhen confusion needs hospital admissionClear signs that mean go todayLactulose: how it works and how to take itThe everyday medicine that prevents episodes
Talk to us
Is your relative's confusion linked to their liver?
If someone with liver cancer is newly confused or drowsy, get them seen at a hospital today. For questions about the plan afterwards, our team can talk it through with the whole family. One helpline serves every CION centre.