1. Grade I: confusion - Inappropriate speech, a reversed sleep pattern, personality changes, fatigue, decreased attention, and poor memory.
2. Grade II: drowsiness - Judgment becomes worse, and you may become drowsy. Asterixis (flapping tremor) may occur when you stretch out your arms and bend your wrists upward.
3. Grade III: semi-coma - You may have hepatic fetor(your breath may have a foul smell). You will sleep most of the time but can still be awakened.
4. Grade IV: coma - The patient cannot be awakened and has entered a coma.

1. Lower the ammonia level in the blood: Take lactulose syrup as prescribed by your doctor. An enema may also be needed to help the body eliminate ammonia.     
2. Eliminate possible triggers:For example, control infection, gastrointestinal bleeding, and alcohol consumption.
3. Avoid taking too much protein and choose suitable foods according to the advice of a nutritionist.

1. Diet: please refer to the Six Food Groups recommended by the Health Promotion Administration, Ministry of Health and Welfare.
   1. Eat high-fiber foods (vegetables and fruit), eat more plant-based protein (tofu and beans)
   2. Avoid high-protein and high-salt foods, such as sausages, ham, cured meat, and cheese.
   3. Take probiotics as instructed by your doctor to help regulate the intestinal flora.
2. Maintain a regular lifestyle: quit smoking, avoid alcohol drinks, avoid staying up late and overworking to reduce the burden of liver. 
3. Prevent constipation. Maintain a bowel movement 2-3 times per day.
4. Take medicine properly under doctor’s prescription. Do not take diuretics, sedative drugs and herbal medicine without doctor’s advice.
5. If visiting a public place is necessary, wear a mask to prevent infections. 
6. Regular outpatient visits. When consciousness changes, or flapping tremor appears, it could be the sign of early hepatic encephalopathy. Please visit a doctor as soon as possible.

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2. Blaney, H., & DeMorrow, S. (2022). Hepatic encephalopathy: Thinking beyond ammonia. Clinical Liver Disease, 19(1), 21-24. https://doi.org/10.1002/cld.1163
3. Fallahzadeh, M. A., & Rahimi, R. S. (2022). Hepatic encephalopathy: Current and emerging teatment moalities. Clinical Gastroenterology and Hepatology, 20(8), S9-S19. https://doi.org/10.1016/j.cgh.2022.04.034
4. Maharshi, S., & Sharma, B. C. (2024). Prophylaxis of hepatic encephalopathy: Current and future drug targets. Hepatology International, 18(4), 1096-1109. https://doi.org/10.1007/s12072-024-10647-9
5. Makhani, S. S., Lee, S., & Bernstein, D. (2024). Preventing readmissions for hepatic encephalopathy. Clinics in Liver Disease, 28(2), 345-358. https://doi.org/10.1016/j.cld.2024.01.001
6. Nardelli, S., Gioia, S., Faccioli, J., Riggio, O., & Ridola, L. (2023). Hepatic encephalopathy - recent advances in treatment and diagnosis. Expert Review of Gastroenterology & Hepatology, 17(3), 225-235. https://doi.org/10.1080/17474124.2023.2183386
7. Sen, B. K., Pan, K., & Chakravarty, A. (2025). Hepatic encephalopathy: Current thoughts on pathophysiology and management. Current Neurology and Neuroscience Reports, 25(1), 28. https://doi.org/10.1007/s11910-025-01415-9