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Hepatic Encephalopathy by Nathalie Smith, MSN, RN

Definition

Hepatic encephalopathy is a problem with the brain that is caused by liver disease. The brain problem may be temporary or permanent. People with a liver disease called cirrhosis are most commonly affected.

Oxygen and Blood Flow to the Brain

Causes

A healthy liver filters out harmful items in the blood like toxins. A liver with disease can no longer filter these toxins. Certain toxins, like ammonia, build up in the blood. The blood then reaches the brain with the toxins. The toxins affect the brain’s ability to work properly.

Risk Factors

These factors increase your chance of developing metabolic encephalopathy:

Certain conditions that affect the levels of fluids and electrolytes (such as hyponatremia, hyperkalemia)
Kidney failure
Infections
Gastrointestinal bleeding
Certain medicines (such as sedatives, anti-epileptics)
Constipation
Cirrhosis
Hepatitis (infectious or autoimmune)

Tell your doctor if you have any of these risk factors.

Symptoms

In the early stages, you may not notice any symptoms. As the condition progresses, symptoms may include:

Changes in behavior and personality
Shortened attention span
Depression and anxiety
Insomnia
Fatigue
Forgetfulness
Disorientation
Slurred speech
Tremor (particularly a flapping tremor of the hands)
Asterixis (rapid momentary loss of tone in the muscles)
Confusion
Stupor or coma

If you have liver problems and any of the above symptoms, call your doctor right away.

These problems can develop quickly. They may resolve when the underlying condition is reversed but immediate treatment is needed.

Diagnosis

This condition is potentially very serious. It can quickly become an emergency. You may need to be hospitalized. Doctors will do an exam to assess the condition of your nervous system.

To assess your liver and kidneys your doctor may order:

Liver function tests
Kidney function tests
Imaging tests of the liver (may be done)

Your doctor may also order tests to assess your brain and nervous system such as:

Images of the brain with MRI scan or CT scan
EEG—looking at brain waves for evidence of encephalopathy and/or seizures.
Lumbar puncture (spinal tap)—looking for other causes of the encephalopathy

Treatment

Hospitalization and Emergency Care

The initial treatment will focus on treating and trying to reverse the underlying problems. If possible, toxins in your blood will be removed or neutralized.

Medications

Medications may be used to:

Neutralize toxins
Treat the condition causing encephalopathy
Reduce recurrence

Dietary Restrictions

Your doctor may recommend changes in your diet. Tube feeding may be needed to supply nutrients, especially in the case of coma.

Transplantation

If this condition is due to liver failure, you may need a liver transplant.

Prevention

To help reduce your chance of getting this condition, take the following steps:

Get early treatment for liver problems.
If you have a disease (such as cirrhosis), see your doctor regularly.
Follow your doctor's instructions or product recommendations for any medication. Avoid overdosing.
Avoid being exposed to poisons or toxins.

RESOURCES:

National Digestive Diseases Information Clearinghouse http://digestive.niddk.nih.gov
National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov

CANADIAN RESOURCES:

Canadian Liver Foundation http://www.liver.ca
Health Canada http://www.hc-sc.gc.ca/index_e.html

References:

Bernuau J. Acute liver failure: avoidance of deleterious co-factors and early specific medical therapy for the liver are better than late intensive care for the brain (review). J Hepatol. 2004;41:152-155.
Butterworth RF. Role of circulating neurotoxins in the pathogenesis of hepatic encephalopathy: potential for improvement following their removal by liver assist devices. Liver Int. 2003;23(suppl 3):5-9. Review.
Hepatic encephalopathy. EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com/about/about-us. Updated August 12, 2012. Accessed September, 2012.
Highleyman L. Hepatitis C. HCV Advocate website. Available at: http://www.hcvadvocate.org/hepatitis/hepC/hepatic_encephalopathy.html. Published 2005. Accessed September, 2012.
Juretschke L. Kernicterus: still a concern. Neonatal Netw. 2005;24:7-9.
Lizardi-Cervera J, Almeda P, Guevara L, et al. Hepatic encephalopathy: a review. Ann Hepatol. 2003;2:122-130. Review.
Metabolic encephalopathy. EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com/about/about-us. Updated August 11, 2009. Accessed September, 2012.
Siegal GJ, Agranoff BW, Albers RW, Uhler MD. Metabolic encephalopathies. In: Basic Neurochemistry: Molecular, Cellular, and Medical Aspects. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
Toftengi F, Larsen F. Management of patients with fulminant hepatic failure and brain edema. Metab Brain Dis. 2004;19:207-214.
4/2/2010 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: FDA approves new use of Xifaxan for patients with liver disease. US Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm206104.htm. Published March 24, 2010. Accessed April 2, 2010.

Last reviewed September 2012 by Rimas Lukas, MD

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