hepatic coma

Hepatic coma is a severe, critical body condition that can cause confusion, disorientation, abnormal neurological signs, loss of consciousness, and death. In fact, this is the last, fourth stage of hepatic encephalopathy.

What is hepatic coma

Hepatic coma is the most severe stage of hepatic encephalopathy. This is a complication (not an independent disease) that can result from acute liver failure or chronic liver disease. As it develops, brain function deteriorates. The brain is a very sensitive organ and requires a healthy liver to function properly. If it is not able to neutralize the toxins that are formed in the body, self-poisoning and brain damage can occur, due to which a person falls into a coma.

A normally functioning liver breaks down and neutralizes the substances formed in the body during digestion. Liver dysfunction allows toxins such as ammonia (produced when the body digests protein), certain fatty acids, phenol, and mercaptans into the bloodstream. From there, they can cross the blood-brain barrier, affect the central nervous system (CNS), and lead to hepatic coma.

Hepatic coma is most common in patients with chronic liver disease. It occurs in 50 – 70% of all patients with cirrhosis of the liver.

Causes of hepatic coma in adults

Heavy drinking and acute infection (hepatitis) are the most common causes of hepatic coma in patients with chronic liver disease.

If the liver is not healthy, the brain will not be healthy either. The liver is an important organ responsible for many vital tasks. Everything that is consumed enters the intestines, where food and drinks are broken down into molecules, which then enter the bloodstream and are sent to the liver.

The liver not only filters out the bad, but also plays an important role in the production of clotting factors (proteins that help blood clot) and helps control blood glucose levels.

When the liver is severely damaged, it can no longer remove these toxic molecules or produce vital elements. In addition, a diseased liver itself releases toxic substances. The combination of all these factors (including the accumulation of toxins in the blood) disrupts the normal functioning of the brain, causing hepatic encephalopathy. If you do not notice the first signs in time and do not start treatment, it progresses to coma.

Here are the main factors that cause encephalopathy and to whom:

Ammonia. This is a substance that bacteria in our intestines produce after the digestion of food (primarily proteins). It is usually removed by the liver. However, if the liver is damaged, ammonia accumulates in the blood and can easily enter the brain.

At elevated concentrations, ammonia is toxic to the brain – it has a direct effect on pH (acid-base balance), metabolism and membrane potential (nerve cell balance). In turn, this leads to numerous changes in the brain, due to which the cells (neurons) do not function properly.

Inflammation and oxidative stress. Toxic products that are formed as a result of these processes in the liver can enter the bloodstream and then to the brain.

Edema of the brain. Cerebral edema, the accumulation of fluid around and inside the brain, often leads to coma. In acute liver failure, cerebral edema contributes to increased pressure in the skull, which can be fatal. Cerebral edema can also occur with cirrhosis.

The accumulation of fluid in the brain is primarily due to the swelling of astrocytes, a special type of brain cell. They work very closely with neurons to help maintain normal brain function. However, swollen astrocytes lead to neuronal dysfunction and therefore to impaired brain function.

Symptoms of hepatic coma in adults

Symptoms of hepatic encephalopathy range from almost imperceptible changes in personality, energy levels, and thinking to deep coma.

An inability to reproduce on paper, for example, a star or other simple drawing (this is called apraxia), and poor handwriting are common symptoms of early encephalopathy.

Decreased brain function can also cause inappropriate behavior, lack of interest in personal care, mood swings, and negative judgments. The patient may be less alert than usual and may develop new sleep patterns. Movement and speech may be slow and difficult.

As the disease progresses, patients lose consciousness, become drowsy, and become disoriented. Breath and urine take on a sweet, musky odor. Hands tremble, outstretched arms flap, toss (asterixis or “hepatic tremor”), and the patient may lose consciousness.

As the coma deepens, reflexes may increase (hyper-reflexia). The toes sometimes fan out when stroking the foot (Babinsky’s reflex).

Sometimes adults experience psychomotor agitation, develop severe symptoms, turning into a coma.

Treatment of hepatic coma in adults

At the moment, there are no sensitive, reliable tests for encephalopathy, especially in its severe course, threatening coma. Therefore, personal observations and professional assessment of the doctor play an important role in assessing the patient’s condition.

Diagnostics

Confusion, disorientation, and other signs of impaired brain function strongly suggest encephalopathy in patients with liver disease. Computed tomography and examination of cerebrospinal fluid do not provide diagnostic clues. Elevated blood ammonia levels are almost always present in hepatic coma, but the levels do not necessarily depend on the severity or severity of the disease.

Magnetic resonance imaging (MRI) can show severe cerebral edema, which often occurs even before coma, electroencephalography (EEG) reveals abnormal brain waves even in patients with early mild symptoms. Blood and urine tests can provide important information about the cause of encephalopathy in patients suspected of taking large amounts of sedatives or other drugs.

Modern treatments

Radical treatment of encephalopathy and hepatic coma is the replacement of a damaged liver with a healthy donor one. In most cases, liver transplant patients improve brain function. However, it is very important to control and prevent coma as much as possible because multiple episodes can lead to permanent brain damage. For this reason, it is extremely important to take care of your brain when you are sick.

Supportive treatment is carried out in intensive care for each cause of coma individually.

Prevention of hepatic coma in adults at home

Maintain a healthy calorie intake. Eat all four food groups, including fruits and vegetables, whole grains and cereals, dairy and meats, or their alternatives.

Limit your intake of salty, sugary and fatty foods.

Avoid alcohol, sedatives, drugs, and any other drugs that are broken down by the liver.

A high-nutrient diet is also important for prevention. It speeds up the passage of food through the intestines, thereby changing the acidity in the intestines and helping to reduce the absorption of ammonia. Controlling your protein intake is important to ensure adequate nutrition and prevent malnutrition and muscle loss.

Popular questions and answers

We asked a series of questions about hepatic coma gastroenterologist Marat Zinnatullin.