Pupillary reaction through the different stages of hepatic encephalopathy

Q: How the pupillary reaction progresses through the different stages of hepatic encephalopathy?


Answer: 

Close monitoring of pupillary changes is an integral and essential part of the management of hepatic encephalopathy as it signifies the level of increased intracranial pressure. 

• A normal response = grade I encephalopathy
• Hyperresponsive = grade II to III encephalopathy
• Slowly responsive = grade III to IV encephalopathy
• Fixed and dilated = probable brainstem herniation

References / further read:

1. Shawcross DL, Wendon JA. The neurological manifestations of acute liver failure. Neurochem Int. 2012 Jun;60(7):662-71.

2. Eelco F.M. Wijdicks, M.D., Ph.D. .N Engl J Med 2016; 375:1660-1670