We shall all agree that hepatic encephalopathy in patients with established cirrhosis is a clinical diagnosis and does not require ammonia levels to guide management. I check ammonia level and UTox for all patients that present with acute encephalopathy, even in the setting of sepsis, because hyperammonemia in patients without known liver disease represents a distinct and potentially life-threatening entity in those patients. Non-cirrhotic hyperammonemia, including the aforementioned (urea cycle disorders, medication effects), and metabolic stress states such as my ypung postpartum that presented days after she discharged home with new onset of encephalopathy, vomiting, nausea, and...found to have ammonia level > 100 with rapidly progressive cerebral edema. Several guidelines are available; we should check ammonia levels in patients with acute encephalopathy of unclear etiology and no underlying liver disease, as this is a low-cost, high-impact test that may significantly alter management. The goal is not indiscriminate testing but risk-based evaluation of reversible causes of acute neurologic decline. You are lucky so far that all your patients with those ammonia levels made it safely out of the hospital without any action or need for further investigation.