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Encephalopathy is a brain lesion. It may seem strange to a person who does not have a medical education and has not previously encountered liver problems: if it hurts in the abdomen, what does the brain have to do with it?
Our expert will tell about this and other important points, Candidate of Medical Sciences, gastroenterologist, hepatologist, lecturer at St. Petersburg State University Maria Prashnova.
What is hepatic encephalopathy
Yes, it turns out that progressive liver disease can affect the state of consciousness and brain activity in general. Moreover, hepatic encephalopathy is a fairly common complication.
– Hepatic encephalopathy is a disorder of brain function caused by insufficient liver function (due to acute or chronic liver failure) and / or the presence of a portosystemic shunt. The latter occurs when blood from the gastrointestinal tract enters directly into the systemic circulation, bypassing the “cleansing” in the liver. Most often, hepatic encephalopathy develops in people with cirrhosis of the liver, says Dr. Maria Prashnova. – PE is one of the most severe manifestations of liver disease, and seriously affects the quality of life of a sick person and his caregivers.
Causes of hepatic encephalopathy
As a rule, according to our expert, the complication develops for two reasons.
The first is a pronounced decrease in liver detoxification function (that is, when it is not able to adequately cleanse the body of toxins). The problem arises when the number of “working” liver cells is not enough, that is, there is an acute or chronic liver failure.
The second reason is the formation of functional or organic shunts (abnormal vessels) between the portal and general circulation systems. In other words, when blood from the internal organs (primarily from the intestines), bypassing the liver, enters directly into the general circulation.
That is, toxic products of intestinal origin penetrate the brain. You can imagine how annoying this is.
“In 90% of the development of episodes of hepatic encephalopathy, provoking (trigger) factors are involved, such as infection, gastrointestinal bleeding, electrolyte disturbances and improper intake of diuretics, as well as constipation,” notes Maria Prashnova.
Symptoms of hepatic encephalopathy
And now – a malfunction in the body, as a result, toxins got to the brain. How does the main organ of the central nervous system react to this?
– Manifestations of hepatic encephalopathy are represented by a wide range of neurological or mental disorders with varying degrees of severity – from subclinical, that is, implicit, to coma, – says Dr. Prashnova. – In mild forms, changes are detected only during psychometric tests focused on assessing attention, short-term memory, psychomotor abilities and capabilities, as well as electrophysiological and other methods of studying the functioning of the brain.
But if the process is already running, the complication begins to progress, and then the patient’s relatives may notice some signs. Apathy, irritability and disinhibition appear, obvious disturbances of consciousness occur.
For example, according to our expert, there are often violations of the sleep-wake cycle – during the day he tends to fall asleep all the time (especially in the car or to the sound of the TV), and activity turns on at night. There may also be disorientation in time and space, inappropriate behavior, sudden excitement or, conversely, stupor. And in a severe case – a coma.
– When examining non-comatose patients, the doctor can identify motor (hypertonicity, hyperreflexia and positive Babinski reflex) and extrapyramidal disorders (hypomimia – weakening of facial expressions, muscle rigidity, bradykinesia – when the movements of the arms and legs slow down, monotony and slowness of speech, trembling of the limbs), – says Maria Prashnova. – However, hepatic encephalopathy is a clinical diagnosis, that is, the doctor focuses on the presence of a complex of symptoms, identifying a trigger and excluding other disorders that lead to impaired consciousness.
That is, similar symptoms can appear in diseases and disorders that are not related to the liver at all. For example, it can be hypoglycemia and ketoacidosis in diabetes mellitus, alcohol or drug poisoning (benzodiazepines, antipsychotics, opioids), dementia and various mental disorders, neuroinfections, electrolyte disorders (hyponatremia and hypercalcemia), intracranial hemorrhage and stroke, multiple organ failure.
In any case, you should not engage in “home diagnostics” – if something bothers you, you should immediately consult a doctor.
Hepatic encephalopathy treatment
The most important thing to know is that the sooner a complication is identified and treated, the better. Hepatic encephalopathy is not a death sentence.
“Injury to the nervous tissue in hepatic encephalopathy in most mild cases is reversible, provided timely detection and treatment,” emphasizes Maria Prashnova. “But in patients with cirrhosis, overt HE, as well as bleeding from varicose veins or ascites, is an indicator of decompensated liver disease. And this in itself is associated with a high risk of death.
You also need to know that in surviving patients, in most cases, the complication comes again. According to a gastroenterologist, relapses occur in 40% during the first year after an episode of overt hepatic encephalopathy.
Diagnostics
Why is this complication most often severe? The fact is that at the earliest stage, the symptoms are not noticeable at all, but even later the patient himself does not notice suspicious signs in himself. And accordingly, to the doctor does not address. Therefore, relatives of a person with a diseased liver should be especially attentive to him.
– A general practitioner, an infectious disease specialist and a gastroenterologist can diagnose this complication, but in the presence of chronic liver disease (especially in the stage of cirrhosis), the ideal option is a quick connection with the attending hepatologist, who knows the specifics of the course of the disease of a particular person.
For diagnosis, it is necessary to determine the severity of the disease – how much the patient is independent or needs care.
– Assessment of the severity of PE is carried out comprehensively. The research strategies used range from simple assessment using clinical scales (for example, West-Haven with 4 stages and the Glasgow Coma Scale for patients with severe disorders) to analysis using complex psychometric and neurophysiological tools, the gastroenterologist explains. – However, none of the methods is standard for assessing the pathological process as a whole. The choice of suitable studies and diagnostic tools depends on the severity of the disease and the impairment of physiological functions.
Modern treatments
To treat overt hepatic encephalopathy, it is first necessary to identify and eliminate the provoking factor, and doctors also prescribe lactulose (a prebiotic) and rifaximin (an intestinal antibiotic).
“Oral branched-chain amino acids (BCAAs), intravenous drugs that affect ammonia metabolism (L-ornithine-L-aspartate), probiotics or other antibacterial drugs may be useful in treatment, depending on the severity and clinical situation,” notes Dr. Prashnova. — Correction of nitrogen metabolism is crucial in the treatment of all stages of PE in patients with cirrhosis, so nutrition plays an important role. Meanwhile, this factor is often underestimated, and 75% of patients with PE have protein-energy insufficiency, accompanied by loss of muscle mass and depletion of energy depots.
Most often, people with diseases of the liver, biliary tract and gallbladder are prescribed the “table number 5” diet. But according to our expert, this diet is not recommended for people with cirrhosis of the liver. Also, with hepatic encephalopathy, you should not follow a low-protein diet, this is wrong.
– Diet therapy consists in frequent fractional meals with increased consumption of kilocalories. Small meals throughout the day and a light snack before bed are recommended. Feelings of hunger should be avoided, says Maria Prashnova. – Of all the nutrients, glucose is the most easily absorbed, however, it should not be used as the sole source of calories. It is also important to get enough protein in your diet. Some protein restriction may be necessary in the first few days of treatment for overt HE, but protein intake should be normalized later on (1,2–1,5 g/kg body weight per day). With poor tolerance, an additional intake of BCAAs is possible.
But it happens that neither medicines nor diets help anymore. Therefore, in severe hepatic encephalopathy, when treatment does not give the desired effect, liver transplantation is performed.
Prevention of hepatic encephalopathy at home
To avoid unnecessary problems and the need for serious intervention, including surgery, it is enough to follow some preventive measures. Here are a few points that should not be ignored in chronic liver disease (especially in the stage of cirrhosis):
- Regular follow-up examination under the supervision of a hepatologist.
- Timely detection and elimination of infections and bleeding (for example, therapy for esophageal varices) as one of the main triggers of PE.
- Monitor the regularity of the chair and the absence of constipation.
- Correction of nutrition and reduction of existing sarcopenia (loss of muscle mass).
“Prophylactic prescription of drug treatment is required in the case of an episode of overt hepatic encephalopathy, as well as in patients with cirrhosis of the liver and a high risk of PE,” notes Maria Prashnova.
Popular questions and answers
Can an MRI show the presence of a disease?
In my practice, there was a case of hospitalization of a patient with cirrhosis of the liver and suspected severe PE. However, the examination revealed an intracranial hematoma, which was the cause of the woman’s confusion. Later, relatives said that a few days ago the woman fell and probably hit her head. This is why it is so important to have caregivers for people with cirrhosis of the liver.