Hepatic encephalopathy occurs when someone with advanced liver disease experiences worsening brain function because their liver is increasingly less capable of clearing toxins from the blood. These toxins build up and eventually make their way to the brain. The condition often starts slowly, and symptoms range from mild to life-threatening as it progresses. Identifying and treating hepatic encephalopathy early can slow its progression but may not cure it if the damage to the liver is too advanced.
Hepatic encephalopathy is common in people with chronic liver disease. As scar tissue takes the place of healthy tissue composed of hepatic cells, normal liver function is impaired. The liver eliminates a lot of toxins and by-products, but ammonia is the most pertinent one when it comes to hepatic encephalopathy. Ammonia is a by-product of protein metabolism; too much of it in the blood has significant effects on the brain.
Cirrhosis is the medical term for permanent scarring of the liver. Without treatment, cirrhosis causes the liver to fail, which is a life-threatening condition. An important thing to realize is that many conditions can cause cirrhosis, including hepatitis, alcohol-related liver disease, non-alcoholic fatty liver disease, and certain metabolic diseases. Hepatic encephalopathy is the most significant complication of cirrhosis and usually appears when the damage is advanced.
By definition, hepatic encephalopathy affects the brain. It manifests in a variety of ways, depending on its severity. Mild symptoms include forgetfulness, mood swings, personality changes, short attention spans, mild confusion, and difficulty with mental tasks such as simple math. As it progresses, symptoms intensify to disorientation, severe anxiety, significant confusion, and an inability to perform mental tasks.
Hepatic encephalopathy manifests with physical symptoms, as well. Mild to moderate cases can present with slurred speech, sweet-smelling breath, difficulty with fine motor tasks like writing, or a change in sleeping habits. In the advanced stages, people may experience shaking arms or hands, sluggish movements, yellowing of the eyes, jumbled speech that is difficult to understand, and extreme sleepiness.
A grading system classifying the stages of hepatic encephalopathy assesses symptoms on a scale from zero to four. Grade 0 can be difficult to detect. Symptoms are extremely mild and may not be noticeable, even to the person experiencing them. The individual and those close to them may attribute excessive work performance issues or traffic violations to any number of other causes. When medical advice is sought, a physician may recommend a neuropsychiatric test to assess thinking abilities. The discovery of deficits will prompt further testing or observation.
As symptoms progress, grading does as well. Grade 1 hepatic encephalopathy causes sleep problems, mood changes, and some difficulty paying attention. Grade 2 is considered moderate, with symptoms such as slurred speech, shaky hands, lack of energy, forgetfulness, and inappropriate behavior. When hepatic encephalopathy reaches grade 3, extreme confusion, behavioral changes, and extreme tiredness develop. Stage 4 is the most severe and occurs when the person loses consciousness, falling into a coma.
Anyone with liver disease is at risk for developing hepatic encephalopathy, but some specific factors can trigger the condition or cause it worsen, including dehydration, GI bleeds, infections, constipation, kidney problems, medications, and surgery. Excessive alcohol is another trigger, as is having a portosystemic shunt, a tube placed in the liver of people with liver damage, to alleviate high blood pressure in and around the organ.
There is no definitive test for hepatic encephalopathy. The doctor will use symptoms, medical history, and a clinical exam to diagnose the condition. Blood tests can also help identify problems with the liver, though these results are not specific to hepatic encephalopathy and should only be used to support a pre-determined diagnosis. Because so many of the symptoms overlap with conditions and events such as brain tumors and strokes, imaging can rule out any issues stemming from the brain itself.
Treatment depends on the severity of the problem and the specific symptoms the person experiences. The doctor will take into consideration the underlying liver condition and evaluate precipitating factors like infection or medications. Then, he will prescribe medications to lower the ammonia level of the blood. Common medications include antibiotics and lactulose, which help eliminate ammonia through the gut. In life-threatening cases of hepatic encephalopathy, patients are likely to require hospital admission and mechanical ventilation.
Managing the underlying condition and taking prescribed medication can lower the risk of developing hepatic encephalopathy. If the liver fails, a transplant is often the only option. There are a lot of things to consider with a liver transplant. The person must be healthy enough to tolerate both surgery and the recovery period, which is lengthy. Donor livers most often come from someone who has died, but, in some cases, living donors can give a portion of their liver.
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