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We must not forget that hyponatremia and hypokalemia are the fluid and electrolyte imbalances most commonly associated with the development of episodic HE, thus serum electrolyte determination is useful.40 Other studies, such as arterial blood gas (acid-base balance, amounts of oxygen and carbon dioxide in blood), blood glucose, serum creatinine, serum urea, and blood urea nitrogen determination, are relevant for making the differential diagnosis.40,41 A differential diagnosis should be carried out in patients with atypical data suggesting focalization (facial hemiparesis or involvement of a cranial nerve, hemiparesis or hemiplegia, no response to sudden stimuli, convulsive crises, aphasia, decorticate posture, Babinski sign) and a history of trauma, or in patients that a priori have neurologic examination data suggestive of other structural alterations of the central nervous system, as well as in patients that show no improvement after anti-ammonia therapy

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