Table 1 Health state descriptions for the five HE health states

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The liver is an organ in the abdomen that processes nutrients and fluids and removes toxins and harmful substances from the blood.

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Liver cirrhosis is the end result of liver damage caused by alcohol abuse or hepatitis or poor diet or obesity or some bile duct diseases.

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Individuals with liver cirrhosis generally present with an enlarged liver and specific blood tests and scans may be required to confirm a liver problem. A liver biopsy may also be required.

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Damage caused by liver cirrhosis is permanent and the liver cannot return to normal. Therefore, the aim of treatment is to prevent further damage and manage any complications.

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Patients with severe liver cirrhosis can develop hepatic encephalopathy. Symptoms include forgetfulness, confusion, personality changes, problems with muscles and movement of limbs and possibly coma. There are five grades of hepatic encephalopathy and the symptoms affect a patient to varying degrees depending on the grade of disease.

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Treatment usually involves medication and changes to diet and lifestyle. If the symptoms cannot be controlled a liver transplant may be required.

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An estimated 58% of patients usually die within one year of experiencing an episode of hepatic encephalopathy and 77% have usually died within three years.

Grade 0

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Patients can experience tiredness, itching, loss of appetite, nausea, weight loss and bruising of the skin.

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Patients may also find it difficult to pay attention and their reaction times may be slower than normal, so it can take longer to complete usual daily activities.

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Patients might see their doctor and receive general advice and minimal treatment.

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Very few patients who remain in Grade 0 will die.

Grade 1

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Patients have the same symptoms as those in Grade 0. However, they may also experience a slight lack of awareness, anxiety, feelings of well-being or happiness.

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These patients may also find it harder to pay attention and have difficulty sleeping and performing usual daily activities.

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Patients are more likely to see their doctor, who would try to establish the cause of the worsening symptoms, and receive general advice and appropriate medical treatment.

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Very few patients who remain in Grade 1 will die.

Grade 2

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Patients in Grade 2 have the same symptoms as those in Grade 1. In addition they may feel very tired, lack energy and become forgetful.

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These patients will take longer than normal to perform usual daily activities and may become disoriented and detached from family and friends.

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Their speech may be slow or slurred and they may not respond to questions as normal.

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They may be irritable and more child-like in their behaviour.

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Patients may be hospitalised for a few days for tests to try to establish the cause of the worsening symptoms, and receive appropriate supportive care and medical treatment. Afterwards, patients may or may not return to the way they were before.

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An estimated 20% of patients in Grade 2 will die.

Grade 3

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Patients in Grade 3 have the same symptoms as those in Grade 2. In addition, they may feel very drowsy or sleepy for long periods or confused and feel as if their brain is unable to function as usual.

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They may be unable to perform usual daily activities, such as reading and writing, and may be unable to respond if someone speaks to them.

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Their body may not be responsive and their speech may be slow or slurred.

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Patients will be hospitalised for a few days or a few weeks for tests to try to establish the cause of the worsening symptoms, and receive appropriate supportive care and medical treatment. Afterwards, patients may or may not return to the way they were before.

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An estimated 56% of patients in Grade 3 will die.

Grade 4

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Patients in Grade 4 will be unconscious in a coma.

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These patients will be hospitalised for a few weeks or maybe even months.

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They will be given tests to try to establish the cause of the worsening symptoms, and receive appropriate supportive care, including oxygen to help them breathe, as well as medical treatment.

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These patients are unable to perform any daily activities while they are in a coma.

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Patients who survive may or may not return to the way they were before.

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An estimated 75% of patients in Grade 4 will die.