**4. Clinical features**

The clinical signs and symptoms of HE may range from mild cognitive impairment to profound coma. These include forgetfulness, alteration in sleep-wake cycle, changes in personality and emotions, hyperreflexia and drowsiness. In more severe cases disorientation, constructional apraxia , asterixis, seizures and eventually coma may develop.(43) It is very important to exclude other causes of altered mental status or encephalopathy (Box B) in suspected patients for appropriate management of HE.


Box B. Differential Diagnosis for HE

Clinically, the most commonly employed criteria used for grading is the West Haven criteria (Table 1) which defines HE semi quantitatively into four grades, based on the presence of specific clinical signs and symptoms and their severity. Further classification of comastose or unconscious patients can be done by using Glasgow Coma Scale which provides a more objective assessment of the conscious state of the patient.(4)
