Hepatic encephalopathy is brain damage caused by metabolic toxins. It is caused by liver damage, usually cirrhosis. Degradation products, especially ammonia, are no longer adequately disposed of. The consequence is, among other things, hepatic encephalopathy.
What is hepatic encephalopathy?
Hepatic encephalopathy refers to a crisis of the central nervous system resulting from liver damage. This involves poisoning of the body due to the accumulation of metabolites in the blood. The pathologically altered liver can no longer break down these “metabolites”. The sensitive nerve cells of the brain in particular suffer from internal intoxication. Doctors distinguish between 4 degrees of severity according to symptoms:
Grade 1: Reduced ability to concentrate and unstable mood.
Grade 2: Extreme fatigue and slight disorientation
Grade 3: Somnolence, speech disorders, severe confusion, motor unsteadiness and incontinence (spontaneous leakage of urine and stool)
Grade 4: unconsciousness and loss of reflexes and pain perception (hepatic coma: coma hepaticum)
Cause
In some textbooks, instead of this 4-stage classification, a distinction of 5 grades of hepatic encephalopathy exists. Hepatic encephalopathy is the result of serious liver disease, most commonly advanced liver cirrhosis. Causes are mostly chronic intoxications of the metabolic organ by excessive consumption of alcohol in alcoholism. Intoxications with drugs or other chemicals can also be decisive. In addition, inflammations of the liver (hepatitis) or of the gall bladder and bile ducts are the reason for liver disease. Under the stressful conditions, the liver is unable to perform its detoxification function or to perform it adequately. The lack of urea synthesis causes an accumulation of ammonia in the bloodstream. In addition, there are other bioorganic compounds such as nitrogenous acids and sulfur compounds. All these metabolites have a particularly toxic effect on the brain and lead to the formation of cerebral edema (water retention in the brain). The result is an increase in intracranial pressure (intracranial pressure), resulting in the mental impairments seen in hepatic encephalopathy.
Symptoms, complaints, and signs
Hepatic encephalopathy is characterized by varying degrees of neurologic and psychiatric symptoms. In mild cases, often no symptoms are noted at all. Or there may be a mild reduction in general condition. In the case of a full-blown hepatic encephalopathy, however, the so-called hepatic coma (coma hepaticum) occurs. In terms of symptoms, the disease can be divided into four stages or degrees of severity. In stage I, mood swings, sleep disturbances, sometimes euphoric states, mild confusion, eye tremors and mild concentration disorders occur. The symptoms may be so mild that they may not even be interpreted as signs of the disease. In the second stage of hepatic encephalopathy, the symptoms become more noticeable. Here, personality changes, memory disorders, fatigue, disorientation, grimacing, and coarse trembling of the hands are among the symptoms. The third stage of the disease is characterized by pronounced sleepiness, severe disorientation, trembling of hands and unclear speech. The patient sleeps all the time, but can still be awakened. In the fourth stage, however, the affected person can no longer be awakened. This is no longer sleep, but a comatose state. The symptoms intensify depending on the speed of the liver failure. In acute liver failure, stage IV of the disease is quickly reached. However, chronic liver disease also often leads to chronic hepatic encephalopathy, in which symptoms may alternate between severe and mild.
Diagnosis and course
Hepatic encephalopathy is initially nonspecific in its symptoms. However, the physician quickly recognizes from the ammonia level in the blood count that a hepatic crisis is present. Nevertheless, other diseases such as sugar shock in diabetes or a stroke must be ruled out in parallel. The findings are confirmed by the usual liver diagnostics with liver values and sonography as well as computer tomography. An EEG reveals the patient’s tendency to suffer seizures.The classification into 4 stages also describes the possible development as the disease progresses. Following acute courses, relapses may occur, while chronicity often progresses to the terminal stage. The onset of death in complete liver failure is also based on hepatic encephalopathy.
Complications
Hepatic encephalopathy develops due to chronic liver disease. In this process, this disease can be harmless, but it can also take a life-threatening course. Initially, the patient may appear drowsy and exhibit poor concentration. In further stages, the affected person may fall asleep more and more with increased muscle tension. This can continue until the affected person lapses into a life-threatening coma (coma hepaticum) with extinguished intrinsic reflexes. Liver cirrhosis also has other complications. For example, due to the scarred remodeling of the liver, its synthesis performance decreases. Fewer proteins are produced than are needed. This leads to a lower oncotic pressure being built up in the blood. This eventually results in more water being squeezed out, leading to the development of edema. The coagulation proteins also become less, and the patient has a prolonged bleeding time. It is not uncommon for a hepatorenal or hepatopulmonary syndrome to develop, which means that the kidneys or lungs can also fail in the course of the disease. Furthermore, the spleen usually enlarges, which causes pain in the left upper abdomen. Varicose veins can develop in the stomach area, which in the worst case can burst, causing bleeding. The risk of developing liver cancer is also greatly increased in cirrhotic patients.
When should you see a doctor?
A physician should be contacted if the individual suffers from a disturbance in concentration over a prolonged period of time. If the usual level of performance drops or there is a persistent lack of drive, a visit to the doctor should be made. If the usual daily obligations can no longer be fulfilled, a doctor should be consulted. If the affected person obviously needs help because he or she can no longer cope with everyday life without a supply, a doctor must take a look at the patient’s state of health. Loss of muscle tone, changes in physical appearance, and disorientation are unusual and should be investigated. Caution should be exercised if there is a disturbance of consciousness. If a loss of consciousness occurs, an emergency physician should be called. To prevent the patient’s demise or lifelong impairment, first aid measures should be administered until emergency medical services arrive. Confusion, trembling of the hands or body, and internal agitation should be examined and treated by a physician as soon as possible. If fatigue, lassitude, disturbances of attention or apathy persist, a visit to the doctor is also necessary. Involuntary twitching of the muscles, discomfort of the eyes or unsteadiness of gait, and dizziness are reasons to consult a doctor.
Treatment and therapy
Therapeutically, hepatic encephalopathy first requires a reduction in ammonia levels. This is done by targeting the intestinal flora, reducing the proportion of ammonia-producing bacteria. For this purpose, the patient is given antibiotics that act mainly in the intestine, as they are absorbed only slowly. Lactulose, an artificial sugar, promotes the growth of lactic acid bacteria, causing the ammonia-forming bacteria to take a back seat. A low-protein diet prevents the intake of an excess of nitrogen from the outset. For the patient, this means a purely vegetarian diet that also contains no eggs or milk or any of their processed products. The physician achieves support of the liver function with drugs that promote the urea cycle, i.e. the elimination of nitrogen. Often the electrolyte balance (minerals) must also be corrected, and in parallel the physician must prevent the threat of exsiccosis (dehydration). In addition, the administration of the trace element zinc is appropriate. In some cases, blood plasma purification must be performed (therapeutic plasmapheresis). Liver perfusion can be improved in some patients. People affected are those who have had prior surgical relief of the portal vein. If the blood pressure of the portal vein is slightly raised again surgically, the result is a better supply of blood to the liver.In cases of total liver failure, only liver transplantation will help as part of the overall course with the complication of hepatic encephalopathy.
Outlook and prognosis
Hepatic encephalopathy can be cured with good and comprehensive medical care. This requires early diagnosis and prompt initiation of treatment. In some patients, symptomatic treatment is already sufficient to achieve lasting relief. Mood swings or liver dysfunction are alleviated by the administration of medication. The healing process of hepatic encephalopathy is generally described as reversible, provided that no other disorders are present and treatment is sought. Without medical as well as drug therapy, the progress of the disease is progressive, since no spontaneous healing is to be expected in this disease. The germs continue to spread in the organism and lead to a deterioration of general health as well as quality of life. In severe cases, the disease progresses despite treatment. The permanently progressive process usually appears with episodic phases. In this clinically manifested hepatic encephalopathy, severe impairments in general lifestyle are observed. In addition, the patients’ risk of death increases significantly. The poor prognosis in these cases is also dependent on the underlying disease present, the overall diagnosis, and the initiation of treatment. However, the chronic course occurs very rarely. Nevertheless, in acute liver failure, the patient is at risk of premature death.
Prevention
Preventing hepatic encephalopathy means sparing the liver with balanced eating and drinking habits. Alcohol and drug abuse, as well as fatty foods, put a strain on the central metabolic organ. Hepatitis infections can be prevented by general food hygiene. These measures serve to prevent
Liver disease and ultimately hepatic encephalopathy.
Follow-up
In most cases, there are no or very few direct aftercare measures and options available to the person affected by this disease that can permanently alleviate the symptoms of the disease. In general, early diagnosis and treatment of the disease has a very positive effect on the further course and can also prevent other complications. Early diagnosis is therefore of primary importance in the case of this disease, so that the affected person should consult a doctor as soon as the first symptoms and complaints appear. In most cases, this disease is treated by taking antibiotics and other medications. The affected person should always ensure that the medication is taken regularly and in the correct dosage in order to permanently alleviate the symptoms. If there are any uncertainties or questions, a doctor should always be consulted first in order to prevent further complications. Antibiotics should not be taken together with alcohol, otherwise their effect is significantly reduced. In many cases, patients are also dependent on taking zinc, although this deficiency can also be controlled by diet. In this case, the doctor can prepare a diet plan for the affected person.
What you can do yourself
Numerous factors precede the changes. For example, the increased intake of proteins is one of the triggers. So is dehydration and hypoxia. Dietary measures are beneficial in chronic hepatic encephalopathy. So is the use of poorly absorbable antibiotics (e.g., rifaximin) to reduce the ammonia-producing intestinal flora or contents. The administration of lactulose is helpful for bowel emptying. You can influence the reduction of protein content yourself through your diet. Avoiding animal meat is also beneficial. Hepatic encephalopathy is a sign of poor liver function, which must be positively influenced. Alcohol and sedating drugs must be avoided at all costs. The spectrum of changes ranges from mild manifestations to coma hepaticus (hepatic coma). To cope better with the disease, it is advisable to join a self-help group. The German Liver Aid, for example, is a non-profit association that was founded by patients 25 years ago.The German Liver Foundation also provides information material and advocates for patients, for example in the form of an advice hotline.
