The approach to the management of patients with HE is summarized in Table 3. Other diagnoses need to be excluded and, after a diagnosis of HE is made on clinical and possibly electroencephalographic grounds, a search made for precipitants. Sedatives and opiates should be avoided, and steps taken to avoid hypoglycaemia, fluid overload or electrolyte imbalance. Protein restriction should be instituted, and disaccharide such as lactitol or lactulose started. Neomycin may be added for more difficult cases for short duration. Branched chain amino acids should not be used routinely, but a trial of flumazenil may be justified for recalcitrant cases.