Hepatic encephalopathy is a devastating and underappreciated complication of cirrhosis that impacts patients, their families, the health care system, and society. Gut-liver-brain axis alterations are key drivers of hepathic encephalopathy-related pathophysiology. These alterations are increasingly being leveraged to enhance diagnostic specificity and treatment targets. The hepathic encephalopathy spectrum includes covert to overt stages; each presents unique challenges in diagnosis, management, and recurrence prevention. Recognizing the challenges and opportunities with currently available hepatic encephalopathy therapies and those on the horizon is critical for improving patient outcomes.