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
- Use of barbiturates or tranquilizers
- Eating too much protein
- Electrolyte abnormalities (potassium decrease from vomiting)
- Complications from shunt placement (TIPS)
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
- 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
- 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.
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.
Acute hepatic encephalopathy may be treatable. Chronic forms of the disorder often keep getting worse or continue to come back.
Both forms may result in irreversible coma and death. Approximately 80% (8 out of 10 patients) die if they go into a coma. Recovery and the risk of the condition returning vary from patient to patient.
- Brain herniation
- Brain swelling
- Increased risk of:
- Cardiovascular collapse
- Kidney failure
- Respiratory failure
- Permanent nervous system damage (to movement, sensation, or mental state)
- Progressive, irreversible coma
- Side effects of medications
When to Contact a Medical Professional
Call your health care provider if any change in mental state or other nervous system problem occurs, particularly if there is a known or suspected liver disorder. Hepatic encephalopathy can rapidly get worse and become an emergency condition.
Treating liver disorders may prevent some cases of hepatic encephalopathy. Avoiding heavy drinking and intravenous drug use can prevent many liver disorders.
If there are any nervous system symptoms in a person with known or suspected liver disease, medical attention should be pursued as soon as possible.
New Treatment Options
Thankfully in the past few year’s there have been recent clinical trials that may offer hope to sufferers of enchephalopathy.
A very special thanks to “GH” from Minnesota, USA who has actually benefited from the research and has shared the following 2 articles with me regarding his success:
Remember your story or comments are always welcome! Keep pressing on!
My mother enter into hepatic coma after she taken anti tb drug for 3 months. The whole family suffer from her condatins. Know she is in hospital for supportive care and lactolose but no change in this 2 weaks. Sir/madam is a chane recovery from the. Plr give inf about the case. Solomon from ethiopia.
Thank you for your comments. I have run across people through this site who have suffered from the effects of encephalopathy, but no one to date who has been in a hepatic coma. Maybe someone will see your comment and offer some insight into your Mother’s condition. Until then I do hope and pray she does get better soon. Keep me posted.
my wife admitted in hosiptal with HE at stage 4, after a month, she is dischrged from hospital as she become stable. now she can walk without support and doing her day to day work. sir, howoften, HE episode will be repeated or how to care her to avoid HE reoccurence. all my family member scared when she was at hospital, and we don’t want those days repeated
Thank you for posting your comments here! Sorry to hear about your wife. What a scary ordeal indeed, I pray your wife will continue to thrive and that she will not have any further episodes to cause you or your family alarm. If she follows the advise of her physicians, and hopefully she is on Pronadolol (beta blockers) plus any other meds they may have prescribed, which possibly includes a blood thinner of some sort, she may be protected from any immediate episodes? At any rate I will continue to pray for her.
All the best,
my husband has hep c and cirrohsis, he was dignoised with liver cancer 2yrs ago. Recently, he had a bleeding varacie and had them banded. Currently he has ascities and has to get tapped almost every week. His been so confused, disoriented and is not himself. Lactulose was prescibed and his so drained. He weighs about 125 and is just not good. I need some insight on how to get him back….he has an appointment with his GI doctor this coming week, but just so sad!
Thank you for your post. I am sorry for your husband’s health issues. It must be so hard to watch this all happening to him. As you likely have read, both here and other articles, Lactulose is a standard form of treatment for Encephalopathy associated with cirrhosis so in that regards I think the doctors have him covered. There may be other and possibly newer treatment protocols I am unaware of so it is good to ask your doctor for his/her advice on this appointment.
When blood bypasses the liver like what is happening to your husband, disorientation and confusion can take place and this is varying degrees. Lactulose is prescribed as a laxative and when it is working it can be very disconcerting, especially when one is so weak as your husband is right now. I am not a knowledgeable person when it comes to natural remedies, and I am thinking more here of something that can replenish his energy levels, but you may want to ask someone who sells and promotes health supplements if they can suggest something for him. I would never stop using the Lactulose unless his doctor says otherwise, but another reason he may be weak is that his electrolytes are down, and he may possibly be dehydrated to some degree? There are products to help in that area, and the one in particular I am thinking of is Gatorade, which is a sports beverage given to players when thirst happens. Do you have or know about this product in your part of the world?
The only thing I can offer and can do is to pray for your husband. I honestly believe that prayer works and God can heal, although sometimes as in my case He has given me tremendous peace to get through some very tough situations as far as my health is concerned.
Keep me posted if you will.