Hepatic encephalopathy is a medical condition in which there is a buildup of toxins in the brain due to chronic liver disease (mainly cirrhosis, liver failure and portal hypertension). This happens because liver helps in detoxification of blood and removal of toxins from the body. However, due to chronic liver disease this function of liver is impaired, thus causing accumulation of toxins in the body including the brain; therefore, hepatic encephalopathy is the result of metabolic abnormalities. This could lead to brain damage from the toxins, which might be presented with mild to severe neuropsychiatric symptoms depending on the severity of underlying cause.
What Are The Causes of Hepatic Encephalopathy?
The exact cause of hepatic encephalopathy is not clearly understood, but it has been hypothesized that the elevation of ammonia and accumulation of its byproduct in the brain cells (astrocytes) cause swelling of the cells and may lead to altered mental state. There are certain diseases that may lead to these conditions such as chronic hepatitis, cirrhosis, liver failure, Reye’s syndrome, portal hypertension and hepatocellular carcinoma. It might also be precipitated by pain medications, diuretics, an infection (such as pneumonia), kidney problems, hypokalemia, dehydration, hypoglycemia, 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, electrolyte imbalance and excessive alcohol consumption.
What Are The Symptoms of Hepatic Encephalopathy?
Various neuropsychiatric symptoms of hepatic encephalopathy depend on the severity of underlying causes ranging from mild to severe. Minimal hepatic encephalopathy shows symptoms of sleep disturbance, memory loss, attention deficit, trouble concentrating and other cognitive changes. Sleep disturbance might be related to underlying anxiety and depression due to medical condition. Cognitive impairment in patients with minimal hepatic encephalopathy usually affects complex activities such as processing of information, attention, writing, driving a car etc; however, daily activities such as dressing, shopping and hygiene are well maintained.
The symptoms in the early stages of hepatic encephalopathy range from foul breath, mild confusion, forgetfulness, change in thinking pattern, changes in sleep patterns, changes in mood or personality, impaired judgment, lack of concentration to impaired fine motor skills such as writing. If the symptoms are not controlled when they are mild then they may progress in severity, which might range from agitation, abnormal limb movements, disorientation, dramatic changes in personality and behavior, slow bodily movements, slurred speech to drowsiness that might lead to coma if not managed on time.
What Are The Stages of Hepatic Encephalopathy?
According to West-Haven Classification, hepatic encephalopathy is categorized into five stages. These include:
Stage 0: This is the stage of minimal hepatic encephalopathy; previously it was known as subclinical hepatic encephalopathy. On examination, there is no detectable change in behavior or personality. There are very mild changes in memory, concentration, coordination and intellectual function. There is absence of flapping tremor (asterixis).
Stage 1: There are noticeable changes in cognition and behavior and personality in stage 1 of hepatic encephalopathy. The attention span is shortened, mild confusion, mild lack of awareness and there is impairment of addition and subtraction. The changes in sleep pattern become noticeable, as there is alteration of somnolence (increased sleeping) with insomnia (lack of sleep). There are alterations of excitement, depression and irritability along with decreased capability to perform mental activities. Minimal signs of flapping tremors (asterixis) are noted.
Stage 2: In stage 2 of hepatic encephalopathy, symptoms increase in severity along with lethargy, apathy, disorientation, irritable behavior, and noticeable personality changes and slurred speech. It is accompanied by moderate impairment in performing mental tasks, drowsiness and obvious asterixis.
Stage 3: The individual is unable to perform mental tasks along with gross disorientation about place and time in stage 3 of hepatic encephalopathy. There is marked confusion, amnesia violent behavior and incomprehensible speech (though still present). The patient is somnolent; however, can be aroused.
Stage 4: The patient goes into coma stage 4 of hepatic encephalopathy with or without response to painful stimuli and cannot wake up.
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