hepatic encephalopathy



Overview

What is hepatic encephalopathy?

Definition of Hepatic Encephalopathy

Hepatic encephalopathy is a central nervous system dysfunction caused by severe acute or chronic liver disease, based on metabolic disorders, with the main clinical manifestations of altered consciousness and behavior or coma.

Types

According to different causes, hepatic encephalopathy can be divided into three types.

Type A: caused by acute liver failure, characterized by acute onset and severe symptoms.

Type B: caused by simple portal shunt without obvious liver injury.

Type C: caused by cirrhosis, one of the most common types of hepatic encephalopathy, characterized by both portal hypertension and portal shunt.

Morbidity

Epidemiological investigations show that the prevalence of hepatic encephalopathy in hospitalized cirrhotic population in China is about 30%~84%.

The prevalence of hepatic encephalopathy is positively correlated with liver function, i.e., the more severely the liver is damaged, the more likely hepatic encephalopathy is to occur.

There is no significant gender difference in hepatic encephalopathy.

Hepatic encephalopathy is most common in people over middle age.

Questions you may be concerned about

What are the main symptoms of hepatic encephalopathy?

Symptoms of hepatic encephalopathy vary depending on the type of primary liver disease, the extent of liver cell damage, the urgency of onset, and the triggers.

Typical symptoms of hepatic encephalopathy include personality changes, behavioral changes, changes in sleeping habits, liver odor, fluttering tremor, and intellectual disability. Accompanying symptoms are visual impairment, impaired consciousness, etc.

Common complications of hepatic encephalopathy include gastrointestinal bleeding, renal insufficiency, disturbance of water electrolyte and acid-base balance, and secondary infection.

How long does a person with hepatic encephalopathy usually live?

The survival time of patients with hepatic encephalopathy depends on the severity of the disease, whether the treatment is timely and whether there are comorbidities.

People with good liver function, who have undergone shunt surgery and whose triggers are clear and easy to remove can usually get better after active treatment.

People with severe disease such as poor liver function generally have a poor prognosis.

How is hepatic encephalopathy treated?

Early recognition and timely treatment are the keys to improving the prognosis of hepatic encephalopathy.

Removal of triggers such as common infections, gastrointestinal bleeding, and electrolyte disorders is important, as well as screening for the presence of abnormal portal shunts.

Promoting ammonia elimination, reducing ammonia production, cleansing the gut, reducing absorption of enteric toxins, and correcting amino acid imbalances are the mainstay of treatment, and drugs such as lactulose, lactitol, and L-ornithine-L-menthionine may be used.

Etiology

Causes

Hepatic encephalopathy is a disease with a complex etiology, and it is currently believed that the formation of hepatic encephalopathy is related to the following factors.

Cirrhosis of the liver.

Severe hepatitis.

Violent liver failure.

Liver cancer.

Severe biliary tract infections.

Acute fatty liver in pregnancy.

Triggers

The disease can be triggered by the presence of the following conditions in people with severe liver disease.

Bleeding in the digestive tract.

Hypokalemic alkalosis.

Inadequate treatment of ascites (large amounts of ascites released over a short period of time).

Intake of large amounts of protein for a short period of time.

Improper use of hypnotic sedatives, anesthetics, and diuretics.

Prolonged constipation.

Uremia.

Surgery.

Severe infections.

Pathogenesis

Disorders of ammonia metabolism may be the main pathogenesis of hepatic encephalopathy.

Ammonia is absorbed into the bloodstream and travels with the bloodstream to the liver, where a healthy liver converts ammonia to urea, which is then eliminated from the body through the kidneys.

When liver function declines or is lost, ammonia cannot be fully converted to urea by the liver, but instead enters the brain with the blood and interferes with brain function, thus causing hepatic encephalopathy.

Symptoms

Symptoms of hepatic encephalopathy mainly include brain symptoms and symptoms of the primary disease.

Symptoms of hepatic encephalopathy vary depending on the type of primary liver disease, the extent of liver cell damage, the onset of the disease, and the triggers. However, they also have their common manifestations, which are generally characterized by personality, behavior, intelligence changes and consciousness disorders.

Typical symptoms

Personality change

It is one of the earliest symptoms of hepatic encephalopathy, which mainly manifests as a big change in personality, for example, people with original extroverted personality manifest depression, while people with original introverted personality manifest abnormal extroversion.

Behavioral changes

It manifests as scribbling, spilling water, throwing paper or cigarette butts, touching, spitting, defecating, etc., and then some meaningless actions and so on.

Changes in sleeping habits

Often manifested as sleep reversal, i.e. activity and work at night and sleep and rest during the day.

Liver odor

It is manifested as the exhaled gas smells like rotten apples, garlic, fishy odor, etc.

It is a characteristic odor emanating from the body such as metabolic intermediates of sulfur-containing amino acids such as methyl mercaptan, ethyl mercaptan and dimethyl sulfide, exhaled through the lungs or emitted through the skin due to liver failure.

Fluttering tremor

It is the most characteristic neurological sign of hepatic encephalopathy and has early diagnostic significance.

The fluttering tremor may occur unilaterally or bilaterally.

This tremor is not characteristic and can also be seen in heart failure, renal failure, and pulmonary failure.

The tremor often disappears after sleep and unconsciousness, and may still be present after awakening.

Intellectual disability

With the progression of the disease, the patient’s intelligence may be altered, manifesting as unclear concept of time and space, blurred concept of people, slurred speech, inverted words, difficulty in writing, and decreased computational power and orientation.

Accompanying symptoms

Visual impairment

Uncommon, visual impairment and blindness may occur, which may worsen with the deepening of the hepatic encephalopathy or recover with the recovery of the hepatic encephalopathy and restoration of blindness.

Impaired consciousness

After the intellectual disorder, there will be obvious consciousness disorder, from drowsiness and lethargy to coma gradually, and all kinds of reactions and reflexes will disappear. There are also cases in which the patient gradually enters a coma from a manic state.

Complications

Common complications of hepatic encephalopathy include gastrointestinal bleeding, renal insufficiency, water-electrolyte and acid-base balance imbalance and secondary infection.

Gastrointestinal bleeding: symptoms such as vomiting blood, black stool or blood in the stool, etc. Dizziness, panic, fatigue, pallor, etc. may occur when the bleeding is heavy.

Renal insufficiency: symptoms such as oliguria and anuria may appear gradually or suddenly.

Hydroelectrolyte disorders and acid-base balance imbalance: a variety of symptoms may appear, such as metabolic acidosis manifestations such as deep and fast breathing, ketone smell (rotten apple smell) when exhaling, and hypokalemia manifestations such as vomiting and diarrhea.

Secondary infection: symptoms such as fever may appear, and coma may also be aggravated.

Consultation

Department of Medicine

Gastroenterology

If you have a history of cirrhosis, hepatitis, or biliary tract disease, or if you develop sudden personality changes, mental decline, behavioral disorders, or muscle clonus, we recommend that you consult a doctor promptly.

Department of Emergency Medicine

It is recommended to seek medical treatment immediately when symptoms such as severe change of consciousness and coma occur.

Preparation for medical treatment

Preparing for medical treatment: registration, preparation of documents, and common problems.

Tips for seeking medical treatment

Before seeking medical treatment, try to record the symptoms you have experienced, their duration, etc. for the doctor’s reference.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Where is the discomfort? How long has the discomfort lasted?

How long have the symptoms lasted? Are they persistent or intermittent?

How has your appetite been recently?

Has there been any recent change in weight?

Have any tests been done and what were the results?

Medical History Checklist

Has anyone in the family experienced similar symptoms?

What is the occupation?

Any other medical conditions diagnosed?

Have any recent medications been taken, such as diazepam?

Any history of drug allergies?

Checklist

Test results for the last 6 months to bring to the doctor’s office

Blood tests

Liver function, blood ammonia

Virology

Coagulation tests

Abdominal ultrasound, head and abdominal CT, abdominal MRI

Electroencephalogram

Medication List

Medication used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office

Hepatoprotective drugs: Liver tablets, Silymarin

Antibacterial drugs: cefuroxime, amoxicillin, vancomycin

Glucocorticoids: dexamethasone, prednisone acetate

Diuretics: furosemide, spironolactone

Diagnosis

Disease diagnosis

The doctor will make a preliminary judgment after understanding the medical history and clinical manifestations, but the diagnosis must be combined with blood biochemistry, electrophysiological examination, psychological intelligence test, imaging examination, and so on.

Medical history

Alcoholism, history of cirrhosis, hepatitis, biliary tract infection, etc.

Clinical manifestations

Symptoms: unexplained cognitive decline, personality changes, abnormal behavior, etc.

Signs: there may be abnormalities in orientation, calculation, etc., and even characteristic signs such as fluttering tremor may be elicited.

Laboratory Tests

Blood test

Blood routine as a routine test is helpful in the diagnosis of this disease.

Blood Ammonia

Blood ammonia is elevated in most cases of chronic hepatic encephalopathy, but can be normal in acute hepatic encephalopathy.

Liver function

Abnormalities in liver function parameters such as bilirubin, alanine aminotransferase, aspartate aminotransferase, albumin, and prothrombin can be seen.

Imaging

Head magnetic resonance imaging and CT examination

Cerebrovascular accidents, intracranial tumors and other brain diseases can be excluded.

Magnetic resonance imaging and CT examination of the abdomen

Helps to diagnose primary liver diseases such as cirrhosis.

Magnetic Resonance Imaging is mainly used for conditions where the diagnosis is unknown by ultrasound and CT, especially when focal fatty liver is difficult to distinguish from liver tumors.

Other tests

Electroencephalography

Electroencephalogram (EEG) records the electrical activity emitted by brain cells, and can be used in hepatic encephalopathy to see if brain activity is affected.

Similar changes can be seen in uremia, respiratory failure, and hypoglycemia.

Evoked potentials

Evoked potentials are electrical potentials generated in the cerebral cortex or subcortical layer of the brain when it receives information about stimulation of various sensory organs.

Evoked potentials are often used in the diagnosis of mild hepatic encephalopathy.

Mental Intelligence Test

Suitable for the diagnosis of hepatic encephalopathy and screening for mild hepatic encephalopathy.

Other similar methods that can be used to detect mild hepatic encephalopathy are the scratch and series of puncture tests.

The disadvantage is that it is affected by age and education level. Older people and those with lower levels of education are slower to perform the test, which can affect the results.

Critical Visual Flicker Frequency Test

Can be used to detect and test for mild hepatic encephalopathy.

Differential Diagnosis

Metabolic encephalopathies such as hypoglycemia and ketoacidosis.

Similarity: Mental abnormality, cognitive impairment and confusion may occur.

Differences: Diagnosis is made through examination of neurological localization signs, combined with imaging and electroencephalography.

Cerebral infarction, hemorrhage and other intracranial diseases

Similarity: Cognitive impairment and personality changes may occur.

Differences: intracranial lesions with history of trauma, infection, blood pressure, dyslipidemia, etc. can be differentiated by neurological physical examination, CT, and lumbar puncture.

Mental disorders

Similarities: Both may present with personality changes, behavioral disorders and other manifestations.

Differences: Unlike hepatic encephalopathy, psychiatric disorders do not have a history of liver-related diseases.

Treatment

General treatment

Remove the cause of the disease

Abstain from chronic alcoholism.

Actively treat primary diseases, such as cirrhosis, acute hepatitis, etc.

Pay attention to rest, avoid exertion, avoid strenuous exercise.

Nutritional supportive therapy should be given.

Pay attention to avoid overeating, and suggest eating small and frequent meals.

Eat more vegetables, fruits and other foods; avoid eating spicy, greasy and other stimulating foods.

Avoid excessive use of unnecessary drugs and health care products, so as not to increase the burden on the liver.

Medication

Bowel cleansing (enema therapy)

Take lactulose, rifaximin and other probiotic preparations and antibiotics orally as prescribed by the doctor, which can reduce the production and absorption of ammonia and avoid aggravation of the condition. Preserved enema therapy can be performed if necessary.

Promote the metabolism of ammonia in the body

Commonly used drugs include L-ornithine-L-aspartic acid, ornithine-α-ketoglutaric acid, etc., which can promote the body’s consumption of ammonia, thus lowering blood ammonia, reducing cerebral edema, and thus relieving symptoms.

Regulation of neurotransmitters

Gamma aminobutyric acid/benzodiazepine (GABA/BZ) complex receptor antagonists, commonly used drugs for flumazenil, can promote the awakening of some of the people who are in the lethargic and comatose stage.

Branched-chain amino acid preparations

These are complex amino acids based on leucine, isoleucine, valine, etc. They are more suitable for people who cannot tolerate protein malnutrition.

Surgery

End-stage liver failure can be treated with liver transplantation.

Liver transplantation is an important surgical procedure for the treatment of end-stage liver disease. It is a process of surgically transplanting a healthy liver into a diseased person to maintain normal physiological function when liver disease from various causes has progressed to an advanced and life-threatening stage.

Liver transplantation should be performed as soon as other medical treatments are hopeless and before the disease reaches a dangerous stage.

Prognosis

Cure

People with good liver function, those who undergo bypass surgery and those whose causative factors are clear and easy to remove usually improve with aggressive treatment.

People with severe disease, such as those with poor liver function, generally have a poor prognosis.

Harmfulness

Impact on daily life

Hepatic encephalopathy may present symptoms such as personality changes, behavioral disorders, consciousness disorders, intellectual disorders, coma, etc., which seriously affects the quality of life.

Life-threatening

Once hepatic encephalopathy occurs, it means that the liver disease is in an advanced or very serious stage, and may be life-threatening if not handled properly.

Complications

Common complications of hepatic encephalopathy include gastrointestinal bleeding, renal insufficiency, water-electrolyte and acid-base balance imbalance and secondary infection.

Daily life

Daily life

Dietary regulation

Control the total calorie intake every day and avoid high-fat, high-protein and high-salt foods.

Ensure energy supply and a certain amount of carbohydrates (staple food) every day.

Eat more fresh green leafy vegetables and fresh fruits with low sugar content.

Moderate supplementation of fermented foods, such as yogurt, can improve the intestinal environment to prevent constipation.

Pay attention to rest

Work and rest on time, do not stay up late, and ensure sufficient sleep.

Adjust your mindset

Keep in a good mood and avoid bad emotions.

Family members or caregivers can give appropriate emotional support.

Use medicines or health products with caution

Most of the drugs and health supplements enter the body to be metabolized by the liver, be careful when choosing drugs and health supplements, not to use drugs without authorization, must be used under the guidance of a doctor to avoid further aggravating the damage to the liver.

Follow-up

Follow the doctor’s instructions for regular follow-up. During the treatment period, if the symptoms are not relieved, or even worsened, or new symptoms appear, you need to go to the hospital in time.

Prevention

Prevention of liver disease is the basis for preventing hepatic encephalopathy.

Patients with liver disease and their family members should know the general knowledge about hepatic encephalopathy and pay attention to avoiding the factors that induce hepatic encephalopathy in their life.

Early detection of mild hepatic encephalopathy and active treatment should be done as far as possible.