Overt hepatic encephalopathy (OHE) and covert hepatic encephalopathy (CHE) are two clinically distinct entities that are at the end of the spectrum of cognitive impairment due to portal hypertension. They are fraught with diagnostic and treatment challenges, but both could result in serious complications if not intervened upon in a timely fashion. CHE has been recognized as a harbinger to OHE providing an opportunity to intervene. There are numerous diagnostic strategies for CHE, and most require specialized equipment, trained personnel, and time. Diagnosis of OHE is significantly easier compared to CHE. As such, the psychometric tests have been more favored due to less dependence on specialized equipment and personnel, and their ability to be equally reliable compared to neuropsychological tests. While we have learned more about the pathophysiology of hepatic encephalopathy, our treatment modalities have not evolved as much. A collaborative approach to management, with development of easier reliable tests, will help us combat this epidemic.