Hepatic encephalopathy – causes, symptoms and treatment

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Hepatic encephalopathy is a neurological disorder that results from an abnormal liver function. The course of the disease ranges from coma to personality and cognitive disorders. Hepatic encephalopathy is the most dangerous complication of liver disease and in many cases is fatal in a very short time. What are the causes and symptoms of HE?

What is hepatic encephalopathy?

Hepatic encephalopathy is a series of neurological and psychiatric disorders that are caused by the liver’s impaired ability to remove ammonia and other toxins from the blood. Ammonia, phenols, mercaptans and fatty acids – these are toxic substances that damage the nervous tissue, leading to mental disorders. This failure is often accompanied by esophageal varices and ascites, which are symptoms of liver cirrhosis. HE is the most common complication of untreated cirrhosis. It is estimated that HE occurs in 30-40% of patients with cirrhosis. Other causes of HE can be both hepatitis and Reye’s syndrome.

Hepatic encephalopathy: types

HE comes in the form of:

1. mild – as a latent form,
2. overt – much more complex and complicated symptoms.

The course of the symptoms of latent HE is most often detectable only with the help of clinical tests. Symptoms on a daily basis are so minimal that they are almost imperceptible. Due to their duration, overt symptoms of HE were divided into episodic, recurrent (if the time to the next episode does not exceed 6 months), and chronic. There are several factors that trigger an episode of hepatic encephalopathy. We include among them:

1. dehydration,
2. constipation
3. infections (e.g. pneumonia),
4. gastrointestinal bleeding
5. kidney problems
6. alcohol abuse,
7. hypoxia,
8. condition after surgery of an organ,
9. eating too much protein
10. taking drugs that depress the nervous system (e.g. benzodiazepines),
11. electrolyte disturbances – e.g. hypokalemia, which is too low potassium in the blood.

Hepatic encephalopathy: symptoms

The symptoms of HE include a number of neurological and psychiatric disorders that determine the intellectual, cognitive and personality areas. The clinical course of hepatic encephalopathy varies greatly. In some patients the disease will progress slowly or even asymptomatically. For others, the symptoms will build up gradually, but the course will be much more turbulent. Often, the closest of the patient say that the patient has changed beyond recognition. Patients show extreme emotions and their behavior can be completely unpredictable.

The symptoms of hepatic encephalopathy include:

1. poor concentration of attention,
2. making mistakes in simple mathematical operations (addition and subtraction),
3. personality changes,
4. mood changes (from euphoria to discouragement)
5. sleep disturbances (lethargy, somnolence),
6. sleep rhythm disturbances,
7. avoid alcohol,
8. significant intellectual impairment,
9. personality changes,
10. behavior inappropriate for the situation,
11. change of handwriting,
12. disturbed orientation in time,
13. confusion is also about the place,
14. no reaction to pain stimuli,
15. coma
16. thick-wavy hand tremor (asterixis),
17. unpleasant odor from the mouth (similar to a musty smell) referred to as foetor hepaticus.

There are 5 degrees of HE in clinical diagnostics. Grade 0 does not show the above-mentioned symptoms, while grade 4 – these are the most severe symptoms, including coma.

Hepatic encephalopathy: diagnosis

Hepatic encephalopathy is diagnosed by:

1. medical interview,
2. laboratory tests (determination of the concentration of: ammonia in the blood, liver enzymes, potassium and sodium levels),
3. electroencephalographic examination (EEG),
4. CHESS scale – the patient answers 9 questions; a result of 0 or 1 indicates no disease and a result of 9 indicates severe disease.
5. exclusion of other diseases – for this purpose additional tests are performed, e.g. CT, MRI, blood glucose level, etc.

Hepatic encephalopathy: treatment

Treatment is based on a diet that limits protein intake to 1-1,5 g / kg body weight daily. Antibiotics and medications are also given to speed up the excretion of toxins from the body, especially ammonia.

HE is reversible as long as specialist treatment is applied early and provided that the patient has no other neurological or metabolic diseases. In a few cases, neuropsychic changes are fixed.

Patients whose HE progresses slowly have a better prognosis for recovery. The remaining patients must take particular care of a proper diet and take appropriate medications to prevent recurrences of hepatic encephalopathy.

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