When the liver fails, toxins such as ammonia that it normally clears build up and reach the brain, causing confusion that can progress to coma. Episodes are often set off by a trigger like infection, bleeding, constipation, dehydration or sedating drugs.
Key symptoms
- Confusion, forgetfulness and personality change
- Day-night sleep reversal and drowsiness
- Yellow skin and eyes, easy bruising
- Swollen belly and leg swelling
- Slurred speech that can progress to stupor or coma
What you find on exam
- Flapping tremor of the outstretched hands (asterixis)
- Jaundice, spider angiomas and red palms
- Ascites with shifting dullness
- Level of consciousness with the Glasgow Coma Scale; sweet, musty breath
Tests
- Liver tests, bilirubin, albumin, INR and blood count
- Ammonia level, sodium, potassium, glucose and kidney function
- Search for triggers: blood and urine cultures, paracentesis for peritonitis, stool for blood
- CT head after a fall, with focal signs or if there is no improvement
Treatment basics
- Lactulose by mouth or enema, adjusted to 2 to 3 soft stools a day
- Add rifaximin to prevent repeat episodes
- Treat the trigger: antibiotics, stop bleeding, correct fluids and electrolytes
- Avoid sedatives; protect the airway if deeply drowsy
- Fall and aspiration precautions; refer for transplant evaluation
Red flags
- Rising drowsiness or a falling Glasgow Coma Scale
- Vomiting blood or black stools
- Fever, belly pain or low blood pressure suggesting infection
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Sources: NCCPA PANCE Content Blueprint; NCSBN 2026 NCLEX-RN Test Plan; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.