Hepatic Encephalopathy: A Serious Complication of Liver Disease

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Hepatic encephalopathy (HE) is a neurological disorder that occurs when the liver fails to remove toxins from the blood. It affects the brain function and causes various symptoms, ranging from mild confusion to coma. HE is a serious complication of liver disease and can be life-threatening if not treated promptly.

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What causes hepatic encephalopathy?

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The liver is a vital organ that performs many functions, such as filtering the blood, producing bile, storing glycogen, and metabolising drugs and hormones. One of its main roles is to detoxify ammonia, a byproduct of protein breakdown, into urea, which is then excreted in urine.

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However, when the liver is damaged by chronic conditions such as cirrhosis, viral hepatitis, or alcohol abuse, it cannot perform its functions properly. As a result, ammonia and other toxins accumulate in the blood and reach the brain, where they interfere with neurotransmission and cause neurological impairment.

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What are the risk factors for hepatic encephalopathy?

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HE can occur in anyone with acute or chronic liver disease, but some factors can increase the risk or trigger an episode of HE. These include:

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• Infections, such as pneumonia or urinary tract infections, which can increase inflammation and ammonia production.
• Gastrointestinal bleeding, such as from varices or ulcers, which can increase ammonia absorption from the gut.
• Constipation, which can slow down bowel movements and increase ammonia retention.
• Dehydration or electrolyte imbalance, such as low sodium or low potassium levels, which can affect brain function and fluid balance.
• Certain medications, such as sedatives, antidepressants, opioids, or diuretics, which can alter mental status or worsen liver function.
• A liver shunt is a procedure that creates a bypass between two veins inside the liver to reduce portal hypertension, which can divert blood flow away from the liver and increase toxin levels.

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What are the symptoms of hepatic encephalopathy?

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The symptoms of HE vary depending on the severity and stage of the condition. They can be classified into four grades:

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Grade 1: Mild cognitive impairment, such as forgetfulness, irritability, inverted sleep-wake pattern, or difficulty concentrating.

Grade 2: Moderate cognitive impairment, such as disorientation, mood changes, personality changes, or slurred speech.

Grade 3: Severe cognitive impairment, such as confusion, somnolence, asterixis (flapping hand motion), or muscle twitches.

Grade 4: Coma, characterised by loss of consciousness and responsiveness.

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How is hepatic encephalopathy diagnosed?

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The diagnosis of HE is based on clinical signs and symptoms after ruling out other possible causes of altered mental status, such as stroke, head injury, infection, or drug overdose. Some tests that can help confirm or support the diagnosis are:

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• Blood tests: To check ammonia levels (which are usually elevated in HE), liver function tests (which are usually abnormal in liver disease), electrolytes (which may be imbalanced in HE), and complete blood count (which may show anaemia or infection).
• Electroencephalogram (EEG): To measure brain waves (which may show characteristic patterns in HE).
• CT scan or MRI: To visualise the brain structure (which may show cerebral edema or other abnormalities in HE).

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How is hepatic encephalopathy treated?

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The treatment of HE aims to remove toxins from the blood and improve liver function. The main strategies are:

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• Supportive care: To provide oxygen therapy, hydration, nutrition, and prevention of complications such as infections or seizures.
• Treating triggers: To identify and treat any underlying or precipitating factors that may have caused or worsened HE, such as infections, bleeding, constipation, dehydration, electrolyte imbalance, or medications.
• Lactulose: A synthetic sugar that acts as a laxative and reduces ammonia production and absorption in the gut by lowering the pH and promoting bacterial growth.
• Antibiotics: Such as neomycin or rifaximin, kill ammonia-producing bacteria in the gut and reduce ammonia levels in the blood.
• Probiotics: Such as lactobacillus or bifidobacterium, promote beneficial bacteria in the gut and reduce ammonia levels in the blood.
• Liver transplant: A surgical procedure that replaces a diseased liver with a healthy one from a donor. It is reserved for severe cases of liver disease with recurrent or refractory HE.

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How can hepatic encephalopathy be prevented?

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The prevention of HE depends on the prevention and management of liver disease and its complications. Some measures that can help prevent or delay HE are:

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• Avoiding or minimising alcohol intake, which can damage the liver and worsen cirrhosis.
• Avoiding or limiting high-protein foods, such as meat, eggs, fish, or dairy products, which can increase ammonia production.
• Avoiding or using with caution medications that can affect the nervous system or liver function, such as sedatives, antidepressants, opioids, or diuretics.
• Getting vaccinated against viral hepatitis, which can cause acute or chronic liver disease.
• Exercising regularly and maintaining a healthy weight, which can improve liver function and prevent fatty liver disease.
• Eating a balanced diet and drinking plenty of fluids, which can prevent constipation and dehydration.
• Seeking medical attention promptly if any signs or symptoms of HE or liver disease occur.

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Sources

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Cleveland Clinic. Hepatic Encephalopathy. https://my.clevelandclinic.org/health/diseases/21220-hepatic-encephalopathy

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Wikipedia. Hepatic encephalopathy. https://en.wikipedia.org/wiki/Hepatic_encephalopathy

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MSN. What is Hepatic encephalopathy and its possible symptoms, causes, risk and prevention methods? https://www.msn.com/en-us/health/condition/Hepatic-encephalopathy/hp-Hepatic-encephalopathy?source=conditioncdx