In hospitalized patients treated for presumed overt hepatic encephalopathy who show no meaningful improvement after 48–72 hours of adequate therapy and precipitant management, what is your highest- yield next diagnostic step and what clinical features drive that prioritization?

At this point in the clinical care pathway, I would repeat an infectious workup (blood, urine, diagnostic paracentesis; occult infections are common in our cirrhotic patients) and perform a high-quality multiphasic cross-sectional imaging test to look for portosystemic shunting that could cause refr...