West Haven Criteria

• Use this tool to support, not replace, clinical judgment, and interpret hepatic encephalopathy grade in the context of baseline cognition and the overall clinical scenario.
• Grades 2–4 are generally considered overt hepatic encephalopathy.
• Lactulose, with or without rifaximin, may be used to treat acute hepatic encephalopathy or prevent recurrence.
• Always consider other causes of altered mental status in these patients, as they are at high risk for comorbidities and complications, including bleeding, infection, drug interactions, and electrolyte disturbances.
• For patients with significantly decreased level of consciousness, consider also calculating the Glasgow Coma Score.
• Reassess grade periodically when mental status changes or after treatment.
• Routine ammonia testing is not necessary to guide treatment.
• For more detailed guidance, refer to local clinical protocols and current guidelines, such as the 2026 American College of Gastroenterology hepatic encephalopathy guideline.

Escalate care urgently for coma, inability to protect the airway, seizures, severe agitation, shock, suspected GI bleeding, or concern for intracranial pathology.