Hepatic Encephalopathy – New Treatment Options

Hepatic Encephalopathy (sometimes called portosystemic encephalopathy) is a potentially-reversible neuropsychiatric anomaly pertaining to liver failure, caused by either chronic (cirrhosis) or non-cirrhotic acute means such as mine.

Best explained toxic substances which are normally removed by the liver accumulate in the blood and end up impairing the brain cells with very unsettling consequences. In short, patients experience altered mental states.   The altered mental state may be subtle and develop slowly over years or be quite obvious and develop rapidly . Often, symptoms of altered mental status can present as inattentiveness, poor judgment, or poor coordination of movements.

As in the case of portal hypertension blood bypasses the filtration system of the liver from the intestines (usually concurrent with esophageal bleeding), and as a result the blood is not purified before reaching the brain. Patients experience signs such as impaired cognition, asterixis (click link for details), and a decreased level of consciousness including coma (referred to as hepatic coma), cerebral edema, and unfortunately death can occur.

One primary function of the liver is to change toxic substances that are either manufactured by the body or ingested (medicines) and make them harmless. However, when the liver is damaged, these “toxins” may build up in the bloodstream.

Ammonia, which is one toxin produced by the body when proteins are digested, is one that is usually rendered nontoxic by the liver. There are many other substances that can build up when the liver function is poor. Any one of them can cause damage to the nervous system.

What can trigger Hepatic Encephalopathy?

• Infections (kidney)
• Bleeding from stomach, esohagus, or intestines
• Low oxygen levels
• Dehydration
• Use of barbiturates or tranquilizers
• Eating too much protein
• Electrolyte abnormalities (potassium decrease from vomiting)
• Complications from shunt placement (TIPPS)

In the case of portal hypertension, hepatic encephalopathy may occur as an acute, and thankfully is potentially reversible. The condition can also occur as a chronic, progressive disorder as related to chronic liver disease.

Symptoms can begin slowly and over time get worse, or they may begin suddenly and be severe from the onslaught. Symptoms can also be mild to start.

List of Symptoms

• Mild Confusion
• Forgetfulness
• Mood or personality changes
• Poor concentration
• Poor judgment
• Altered thinking
• Altered sleep patterns
• Musty or sweet breath
• Loss of small hand movements
• Decline in handwriting skills
• Drowsiness
• Confusion
• Disorientation
• Agitation
• Inappropriate behaviour
• Severe personality changes
• Slurred speech
• Slowed or sluggish movements
• Seizures which are rare can also occur

In severe cases encephalopathy sufferers can become unresponsive, unconscious, and sometimes they can end up in a coma.  Due to the nature  of these symptoms many patients are unable to care for themselves.

Testing or Exams

• Blood pressure testing (low or high)
• Blood counts or CBC testing for infections or loss of blood
• Metabolic testing (checking blood levels for ammonia, glucose, electrolytes, lactate, oxygen, and enzyme levels in the liver)
• Tests for toxin levels or drugs such as alcohol, amphetamines, and many others
• CT and MRIscans searching for brain swelling, anatomical abnormalities or infections
• Body fluid cultures or blood tests analyses to determine infections
• Kidney function tests
• Doppler ultrasound (abnormal blood flow to tissues, abscesses)
• Ecephalogram or EEG testing for brain damage or brain wave patterns that may not be normal
• Auto-antibody analysis (dementia caused by antibodies that destroy neurons)

The above list is not all the tests a physician may order to reach a diagnosis, but sometimes specific testing is ordered according to the history or given symptoms of the patient.

Treatment

Hepatic encephalopathy is an acute medical condition that may become a medical emergency. Hospitalization is required.

Treatment may include life support, treatment or elimination of related factors, and removal or neutralization of ammonia levels or other toxins.

Life support if required, includes support of breathing or circulation, predominantly if a coma develops. The brain may swell, which also can be life-threatening.

Gastrointestinal bleeding  from esophogeal varices must be stopped. The intestines need to be emptied of blood. Infections, electrolyte abnormalities (especially potassium), and kidney failure need to be treated.

Patients with severe, repeated cases of encephalopathy may be told to make changes in their diets, and especially reduce the amount of protein intake.   Dietary counseling is important, because too little protein in the diet may cause malnutrition.  Critically ill patients may need specially formulated intravenous or tube feedings.

Lactulose may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to remove blood from the intestines. Neomycin may also be used to reduce ammonia production by intestinal bacteria. Rifaximin, a new antibiotic, is also effective in hepatic encephalopathy.

Sedatives, tranquilizers, and any other medications that are broken down by the liver should be avoided if possible. Medications containing ammonium (including certain antacids) should also be avoided. Other medications and treatments may be recommended. They may have varying results.