Hepatic Encephalopathy - Signs, Symptoms, Diagnosis, and Treatment

Introduction:

We have only one liver, and it is the most important organ of our body. The liver performs many body functions, including the excretion of toxins, filtration production, and synthesis of bile, metabolization of a wide range of medications. Diseased conditions in the liver can lead to various systemic problems. Hepatic dysfunction can increase many toxins in the blood; these substances may be the cause of a wide range of systemic conditions, one of which is hepatic encephalopathy.

What Is Hepatic Encephalopathy?

Loss of brain function, a neuropsychiatric problem in individuals with severe liver disease, is hepatic encephalopathy. This condition can be divided into two types:

1. Covert Hepatic Encephalopathy - A subclinical condition with less severe manifestation but has a significant impact on the quality of a patient’s life, employment, and driving skills. It leads to a high risk of hospitalization and death.

2. Overt Encephalopathy - A reversible neurological condition caused by severe liver disease like cirrhosis. It is associated with a lower rate of hospitalization and death.

What Causes Hepatic Encephalopathy?

The process underlying the occurrence of this condition is exactly unknown, but the high levels of a substance that are released by the digestive system's breakdown of protein are believed to play a major role in this.

One such substance is ammonia. Elevated levels of ammonia in an individual with severe liver disease have a great impact on the functional loss in brain and other disorders such as Reye’s syndrome (a rare condition that causes swelling in the brain and liver) and other metabolic disorders.

Ammonia is highly toxic to the brain, and normally it is converted to urea in the liver and excreted through urine out of the human body. But in the diseased condition, this system fails, and a rise in high levels of ammonia occurs. Though in some cases, elevated ammonia fails to show any symptoms, concluding that there are additional factors for the occurrence of this disorder.

What Are the Liver Conditions That Causes Hepatic Encephalopathy?

Any condition which causes immense damage to the liver and its function can lead to hepatic encephalopathy. The diseases of the liver like hepatitis, end-stage liver disease cirrhosis, portal hypertension, and Reye’s syndrome can be responsible for this condition. Subtle signs of this condition are observed in nearly 70 % of cirrhosis patients.

What Are the Signs and Symptoms of Hepatic Encephalopathy?

Signs and symptoms vary from person to person. For some individuals, the symptoms have episodes of occurrence (they may come and go), and for others, it may start slowly and get worse bit by bit. And sometimes it may hit hard suddenly. We need to check for the following signs:

• Amnesia (forgetfulness).

• Confusion.

• Extreme emotions like nervousness or excitement.

• Sudden differentiation in social behavior.

• Crankiness.

• Sudden change in one’s personality.

• Anhedonia (loss of interest in things around).

• Insomnia (sleeplessness at night).

• Hypersomnia (extreme sleepiness even during daytime).

• Euphoria (an extremely strong feeling of happiness).

What Are the Precipitating Factors For Hepatic Encephalopathy?

Some factors that can worsen hepatic encephalopathy are:

• Any kind of severe infection.

• Excessive alcohol consumption.

• Constipation.

• Medications like painkillers, sleeping pills, antidepressants, and tranquilizers.

• Renal issues (kidney problems).

• Bleeding in your gastrointestinal tract (stomach, intestine, or esophagus).

• Any critical surgery.

• Dehydration.

• Portosystemic shunt - Individuals with severe portal hypertension, undergo a surgical procedure of placing a tube in the liver to reroute the pressure and blood flow in the portal vein; this procedure is called TIPS (transjugular intrahepatic portosystemic shunt).

How Is Hepatic Encephalopathy Diagnosed?

The early stages of hepatic encephalopathy are hard to diagnose, and mild changes in your behavior and personality are noticed by friends and family. If you have any history of liver disease and along with that, if you have a mild change in personality and behavior, you are recommended to undergo the following tests to examine the associated brain disorder:

• Psychometric tests are useful in the diagnosis of minimal cases of hepatic encephalopathy.

• Check on high levels of arterial or serum ammonia levels.

• EEG (electroencephalogram) is a diagnostic test that shows high amplitude low-frequency waves and triphasic waves.

• MRI scans (magnetic resonance imaging).

• Visual evoked responses that show classic responses with Hepatic encephalopathy.

• CT scans (computed tomography).

What Is the Treatment Provided for Hepatic Encephalopathy?

The treatment used to treat hepatic encephalopathy differs for each individual. The therapy is based on factors that trigger the condition, age, general health, symptoms, severity of the disorder, and the underlying liver disease. Initial treatment is based on the identification and removal of the trigger event like gastrointestinal bleeding, certain medication or drugs, or any kind of severe infection. Appropriate therapies are provided to treat and manage the infection and control bleeding and other factors.

• Methods to control and reduce the levels of ammonia are done.

• Lactulose or bowel movements are used to remove nitrogen load from the gut.

• Lactulose or lactitol, LOLA L-ornithine, and L-aspartate precipitation increase the use of ammonia in urea.

• Synthetic sugars such as lactose have been used that increase the speed of the food passage through the GIT (gastrointestinal tract), which prevents the absorption of toxins.

• Antibiotics like Rifaximin, Neomycin, Metronidazole, or Vancomycin are used to treat the underlying infection.

• Rifaximin (Xifaxan) reduces the risk of overt hepatic encephalopathy and the number of hospitalizations due to it.

• It is recommended to avoid sedative drugs.

• A zinc supplement is provided in case of deficiency.

• Hepatic encephalopathy is associated with an impairment of dopaminergic neurotransmission and insufficient evidence of dopamine agonists are a benefit to patients.

• Earlier restriction in protein intake was found to be beneficial, but adequate nutrition was found to be essential in conditions like cirrhosis so, the increased requirement for protein is recommended in this condition.

Conclusion:

Hepatic encephalopathy is caused by the toxins which accumulate in the blood and travel to the brain. The toxins which normally get cleared from the body by the liver. Hepatic encephalopathy in patients with cirrhosis is associated with a worse prognosis and leads to frequent relapses. The signs and symptoms of hepatic encephalopathy are often reversible when identified, managed, and treated as early as possible. Individuals with chronic liver disease are at high risk of reoccurrence of this condition, so they have to be periodically monitored by the health care provider.