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When there are no signs or symptoms of HE, high ammonia levels, alone, should not indicate treatment for HE.30,31 Despite the above, much more recent evidence reveals that, in addition to aiding in making the differential diagnosis of HE, normal ammonia values, even though possible in HE, can justify reconsidering the diagnosis.32,33 Serum ammonia testing offers little additional benefit in clinical settings with a high or low pre-test probability for HE

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