Chinese guidelines on management of hepatic encephalopathy in cirrhosis

Table 4 Hepatic encephalopathy classification, symptoms, and signs

Revised HE grading criteria	Neuropsychiatric symptoms (that is, cognitive function)	Nervous system signs
No HE	Normal	Normal nervous system signs, normal neuropsychological test results
MHE	Potential HE, no noticeable personality or behavioral changes	Normal nervous system signs, but abnormal neuropsychological test results
HE grade 1	Trivial and mild clinical signs, such as mild cognitive impairment, decreased attention, sleep disorders (insomnia and sleep inversion), euphoria, or depression	Asterixis can be elicited and neuropsychological tests are abnormal
HE Grade 2	Marked personality or behavioral changes, lethargy or apathy, slight orientation abnormality (time and orientation), decreased mathematical ability, dyskinesia, or unclear speech	Asterixis is easily elicited, and neurophysiological testing is unnecessary
HE Grade 3	Marked dysfunction (time and spatial orientation), abnormal behavior, semi-coma to coma, but responsive	Asterixis usually cannot be elicited. There is ankle clonus, increased muscle tone, and hyperreflexia. Neurophysiological testing is unnecessary
HE Grade 4	Coma (no response to speech and external stimuli)	Increased muscle tone or positive signs of the central nervous system. Neurophysiological testing is unnecessary

HE: Hepatic encephalopathy; MHE: Minimal hepatic encephalopathy.