Hepatic encephalopathy (HE)

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HE is a syndrome characterised by neuropsychiatric abnormalities resulting from severe liver disease such as cirrhosis. In hepatic dysfunction there is inadequate elimination of metabolic products resulting in the accumulation of neurotoxic metabolites. More than 40% of people with cirrhosis develop hepatic encephalopathy

Causes

  • Accumulation of neurotoxic metabolites like ammonia
  • Renal failure
  • Gastrointestinal bleeding
  • Infection
  • Constipation
  • Medications may worsen HE (CNS depressants such as opiates, benzodiazepines, antidepressants, and antipsychotic agents
  • Diuretic therapy

Signs and symptoms

Grade

Symptoms

Signs

Grade 0

Mild decrease in intellectual ability and coordination

−      Inability or difficulty to build, assemble, or draw objects.

−      Increased risk of traffic accidents

Grade 1

Trivial lack of awareness

−      Altered performance of addition or subtraction

−      Shortened attention span

−      Insomnia, or inversion of sleep pattern

Grade 2

 Lethargy or apathy

−      Disorientation for time or place

Grade 3

 Somnolent but can be aroused

−      Gross disorientation

−      Unable to perform mental tasks

−      Amnesia

−      Incoherent speech

Grade 4

 Coma

 

Differential diagnosis

  • Intracranial lesions (haemorrhage, tumour, abscess etc.)
  • CNS infections (encephalitis, meningitis)
  • Other metabolic encephalopathies (uraemia, hyper/hypoglycaemia etc.)
  • Hypertensive encephalopathy
  • Alcohol intoxication
  • Drug toxicity e.g. sedatives, heavy metals

Investigations

  • Liver function tests
  • Electrolytes and urea
  • Prothrombin time (INR)
  • Blood glucose
  • Electroencephalography (EEG)
  • Full blood count

Treatment objectives

  • Recognize and treat precipitating factors
  • Reverse neuropsychiatric symptoms
  • Minimize nitrogenous substances
  • Treat underlying factors

Non-pharmacological treatment

  • Reduce protein intake - 1.25-1.5g/kg per day
  • Increase carbohydrate intake
  • Maintain fluid and electrolyte balance

Pharmacological treatment

Lactulose oral

10-30 mL three times daily orally to achieve 2-3 loose stools per day

Metronidazole oral

400-800 mg every 8 hours

Vitamin K (Phytonadione) IM

10 mg intramuscularly

Prevention

  • Avoid precipitating factors
  • Diagnose and treat liver disorders early

Referral

  • Specialist referral for severely ill patients
  • Specialist referral for all children