Reviewed By: Pramod Kerkar, MD, FFARCSI

Hepatic encephalopathy is defined as brain function deterioration due to impairment in liver function caused by severe liver disease. It is also known as portosystemic encephalopathy or liver encephalopathy. Hepatic encephalopathy happens because one of the many functions of liver is to detox body of any toxins, but due to impaired liver function, there is decreased detoxification leading to neuropsychiatric symptoms.

Is Severe Hepatic Encephalopathy Reversible?

Only in rare cases the severe hepatic encephalopathy is non-reversible. The treatment is aimed at elimination of precipitating factors such as an infection (such as pneumonia), kidney problems, dehydration, post-surgery trauma, hypoxia (low oxygen levels), immunosuppressant medications, consumption of excess amounts of protein, medications that suppress central nervous system (such as barbiturates or benzodiazepines), gastrointestinal bleeding, hypokalemia or electrolyte imbalance, hypoglycemia, excessive alcohol consumption, pain medications and diuretics. Treatment also involves reducing the load to gut nitrogenous waste. The management includes dietary control, lactulose and antibiotic therapy.

Dietary Control: Generally, patients are advised to limit protein intake, as ammonia is the byproduct of protein metabolism. However, prolonged restriction of protein might lead to malnutrition. Protein sources such as animal meat, fish, cheese and eggs are avoided; however, vegetable sources can be eaten such as soy protein.

Lactulose Therapy: It is a synthetic sugar that is usually taken orally in the dosage of 30 to 40 ml twice a day, severe cases of hepatic encephalopathy may be treated with 30 ml 2 to 4 hourly. Comatose patients can be given enema (300 ml lactulose and 700 ml water). Caution should be taken not to overdose as it might lead to flare up of hepatic encephalopathy symptoms. Overdosing symptoms include severe diarrhea, electrolyte imbalance and hypovolemia. It helps in clearing up the intestinal load of ammonia and decreases ammonia absorption by the body.

Antibiotics: They are used in combination with lactulose to stimulate healthy gut flora. Probiotics can also be taken along with antibiotics.

In general, hepatic encephalopathy is usually reversible with treatment depending on the underlying cause; however, in rare cases of severe hepatic encephalopathy where treatment is delayed, it might lead to permanent hepatic encephalopathy.

What Are The Signs And Symptoms Of Hepatic Encephalopathy?

Generally, the clinical course of hepatic encephalopathy is transient and short-term, but in some cases, hepatic encephalopathy becomes chronic or long-term medical condition. In addition, in chronic cases, hepatic encephalopathy can become permanent or recurrent. People with recurrent hepatic encephalopathy have the episodes throughout their lives. In permanent cases, the symptoms are persistent where the treatment was unresponsive.

The classic signs and symptoms of hepatic encephalopathy usually include various neuropsychiatric disorders, varying from minor deficits (alteration of sleep cycle, mood swings, memory problems and lethargy) to serious deficits (deep coma, cerebral edema or brain stem herniation).

The symptoms of hepatic encephalopathy can be grouped under altered level of consciousness, neuropsychiatric changes and neuromuscular changes.

Alteration of Consciousness Level: This includes mild confusion that can progress to coma. They are preceded by lethargy and/or stupor. Confusion is characterized by transient alteration in mental state with alteration in attention span along with various cognitive deficits such as forgetfulness, disorientation and slurred speech. Patient shows signs of excessive drowsiness and if not corrected then it may lead to coma, which is a state of consciousness when patient does not respond to any external stimuli.

Neuropsychiatric Alteration: The signs and symptoms of hepatic encephalopathy that affect neurology and psychiatry of a patient include changes in intellect, conscience, personality and behavior. There is slowness in processing information and responding to it along with time and place disorientation. The personality and behavior changes include irritation, apathy and changes in sleep cycle. In severe cases, delusions may also be noted.

Neuromuscular Alteration in Hepatic Encephalopathy: These include changes in muscular behavior due to altered or weakened nerve signals. There are hepatic encephalopathy symptoms of hyper-reflexia (exaggerated reflexes) or hypo-reflexia (reduced reflexes) or absence of response to painful stimuli. Babinski sign (upward movement of toe after stimulation of the plantar aspect of the foot) is also noted along with asterixis (tremor of hands) and flutter tremors (tremors of upper extremities).

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Pramod Kerkar

Written, Edited or Reviewed By:

, MD,FFARCSI

Pain Assist Inc.

Last Modified On: August 11, 2018

This article does not provide medical advice. See disclaimer

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