The features of hepatic encephalopathy (HE) are various. Slight ataxia combined with hypomimia, dysarthria and flapping tremor may represent HE just as minimal changes in personality or psychomotor slowing. Diagnosis of HE is made difficult by the fact that there is no symptom or serum biochemical test result that may produce evidence for the presence of HE. Thus we are forced in each case to exclude other possible causes for the patient’s neuropsychiatric symptoms before diagnosing HE. The diagnosis of HE requires to put together clinical findings, serum test results, neuropsychological and neurophysiological test results and in some cases even cerebral imaging results like pieces of a puzzle. But, ultimately HE is proven only in case that the symptoms disappear with adequate therapy.