Hepatic encephalopathy: confusion and altered awareness
Content date: 10 November 2026
New confusion in someone with liver disease needs urgent assessment. Simply increasing lactulose at home is not enough. Family members often notice the first changes.
Your next step
Keep the written lactulose plan, medicine list and instructions for altered awareness readily available.
Get urgent help: Any new confusion or unusual drowsiness needs urgent assessment. Difficulty waking, sudden limb weakness, seizures or breathing difficulty require emergency services immediately.
What is hepatic encephalopathy?
- Brain function can be disturbed when the liver cannot adequately process substances coming from the bowel, or blood bypasses it through other vessels. This may occur with advanced cirrhosis or after TIPS, causing slow thinking, altered sleep or behavior, confusion and drowsiness.
- Not all confusion is caused by the liver: infection, stroke, low glucose, electrolyte problems or medicines are other possibilities. An ammonia result alone neither establishes the diagnosis nor determines its severity.
What can trigger an episode?
- Triggers include infection, gastrointestinal bleeding, constipation, dehydration, kidney problems and sedating medicines. The team looks for and treats the trigger rather than focusing only on ammonia. Do not add sleeping tablets, strong painkillers or herbal products without review.
How are preventive medicines used?
- If lactulose is prescribed, the usual goal is 2–3 soft stools daily under your written plan, not watery diarrhea. Severe diarrhea and dehydration can worsen the problem. Your team should explain dose adjustment and what to do for constipation or diarrhea.
- Rifaximin may be added to reduce recurrence in selected patients. Do not stop preventive treatment simply because concentration improves, or wait for a dose to work when new confusion appears.
How can family members help?
- Record changes in sleep and concentration, bowel movements and medicines. Maintain regular meals and adequate protein; do not restrict protein because of confusion. Someone with altered awareness must not drive or be left alone.
- If the person is difficult to wake or cannot swallow safely, give nothing by mouth and call emergency services. After recovery, review the recurrence-prevention plan; episodes may warrant transplant evaluation.
When to get help
Any new confusion or unusual drowsiness needs urgent assessment. Difficulty waking, sudden limb weakness, seizures or breathing difficulty require emergency services immediately.
Persistent constipation or diarrhea without confusion, difficulty following treatment or running out of medicine: contact the team the same day.
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