Hepatic encephalopathy (HE) or portosystemic encephalopathy (PSE) is a serious neuropsychiatric disorder resulting from liver failure. It is one of the common complications of liver cirrhosis and portosystemic shunting (PSS). Ammonia accumulation is one of the well-established causes. Ammonia is a by-product of the intestinal bacteria as a result of the breakdown of dietary supplements. In the normal state of the liver, the peripheral hepatocyte contains glutaminase that converts glutamine into glutamate and ammonia; ammonia will be detoxified and converted into urea. The variant manifestations were linked to the severity of HE. A wide range of neurological and psychiatric signs have been reported. The International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) uses asterixis (i.e., flapping tremor) as the first clinical sign of HE. Four factors should be taken into consideration to classify and distinguish HE from other conditions: HE type, severity of manifestations following West-Haven Criteria (WHC), HE time course, and presence of precipitating factors. Nonabsorbable disaccharides (lactulose and lactitol) and rifaximin have been the standard of care as first- and second-line therapies, respectively. Non-pharmacological interventions had a crucial role in HE management. Liver transplantation is the ultimate management of hepatic cirrhosis
