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Criteria for Grading Hepatic Encephalopathy Print E-mail
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Written by G. Firman MD   
Monday, 30 January 2017 06:52


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 behavior

3

Somnolence to stupor, responsiveness to stimuli, confusion, gross disorientation, bizarre behavior

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




References:

  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.

Last Updated on Wednesday, 19 April 2017 05:04
 

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