If you’re reading this, you or someone you love might be facing something called hepatic encephalopathy. You might be wondering what tests are good for HE. First, I want to say: you’re not alone. I’ve been there. It can be scary and confusing, but knowing what’s happening in your body can help you feel less afraid.
Let me walk you through what I’ve learned—patient to patient. I wish I had known some of the common tests, but to be honest, I was so afraid of getting labeled crazy or getting stigmatized that I hated the words hepatic encephalopathy or HE. I avoided the discussion and that’s why I love talking about it now. I felt so helpless and want you to know that you may lose control, but you also have options. 
Hepatic Encephalopathy or Brain Fog
Hepatic encephalopathy is a problem with the brain that happens because the liver isn’t working well. Your liver usually cleans out harmful toxins in your blood—like ammonia—that come from food and waste. But if the liver is damaged (like from Hepatitis, PBC, MASH, NASH or Cirrhosis), these toxins build up and go to your brain. That’s when HE symptoms can start.
There are two types:
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Overt HE – This means the symptoms are visible. You are acting a little wacked. You might feel confused, forgetful, sleepy, or even act a little off. Sometimes people get shaky hands or have trouble speaking clearly. I was in denial about my HE and hid it as much as possible.
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Minimal HE – You might not notice anything strange, but special tests can show it’s affecting your thinking. It can sneak up and affect things like your memory, mood, and even your driving. Well, it’s like a spectrum, I would have minimal and then it would be overt. It can change on a day to day or meal by meal basis.
Who Gets It?
If you have cirrhosis, you have a higher chance of getting HE. Around 3 or 4 out of every 10 people with cirrhosis will have overt HE at some point. Even more—up to 80%—may have minimal HE without knowing it.
For some, it starts after a procedure called TIPS, which is used to reduce pressure in the liver. It’s helpful especially if you are already brain foggy. Your doctor might recommend it. I didn’t have one, but tried to stay compliant with all my Lactulose or Xifaxin. Check out my Zoney youtube here.
It can look different for everyone. Some common signs include:
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Feeling foggy or out of it
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Sleep problems (like staying up all night and sleeping all day)
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Trouble remembering or concentrating
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Being more moody or irritable than usual
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Slurred speech or trouble writing
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Shaky hands (called asterixis—a flapping motion when you hold your arms out)
In serious cases, people might get very sleepy or go into a coma. That sounds scary, but with the right care, most people get better.
What Tests are Good for HE?
Doctors usually figure out if you have HE by looking at your symptoms and ruling out other problems, like infections, low blood sugar, or medication side effects.
If your symptoms are mild, they might give you a test where you connect numbers or colors in a certain order. This helps show how your brain is processing information. They may also do blood tests or brain scans to rule out other causes, but tests for ammonia levels in your blood aren’t always reliable—it’s your symptoms that matter most.
What’s the Treatment?
Thankfully, there is treatment—and it works for most people.
1. Lactulose (first-line treatment)
This is a sweet liquid you drink. It helps your body get rid of ammonia through your poop. Yes, poop is part of the solution! The goal is to have 2–3 soft bowel movements a day. If you’re in the hospital and can’t swallow, they can give it through a tube or as an enema.
2. Rifaximin (add-on treatment)
If lactulose alone doesn’t do the trick, they might add this antibiotic. It changes the bacteria in your gut to make less ammonia. It works well and has fewer side effects.
3. Nutrition
Many of us think we should eat less protein, but that’s actually not true. Your body needs protein to help your muscles clear out toxins. Most people with HE should eat 1.2 to 1.5 grams of protein per kilogram of body weight every day. Small meals and a bedtime snack can help keep your brain steady.
4. Treating What Triggered It
Sometimes, HE flares up because of things like constipation, infection, dehydration, or certain medications. Fixing these can make a big difference.
Can It Come Back?
Yes—but you can help prevent it. Once you’ve had HE, your doctor might want you to stay on lactulose or rifaximin long-term. It’s also important to keep regular follow-up visits, take your medicine as directed, and avoid things like alcohol or sedating medications.
If your HE is severe or keeps coming back, your doctor might talk with you about liver transplant. It’s a big step, but for some, it’s a life-saving one.
Final Thoughts from Someone Who’s Been There
HE is a tough part of living with liver disease, but it’s not the end of the road. When I was first diagnosed, I felt ashamed, foggy, and frustrated. But learning what was happening gave me power. Treatment helped me feel more like myself again.
Please know that you’re not broken—you’re battling something real. Talk with your doctor. Ask questions. Keep notes. Keep going.
And if no one’s told you yet today: you are doing better than you think.
