Hepatic Encephalopathy - Symptoms, Treatment, Stages

2024 Author: Rachel Wainwright | [email protected]. Last modified: 2024-01-15 19:51

Hepatic encephalopathy

The content of the article:

1. Forms of the disease
2. Causes and risk factors
3. Stages of hepatic encephalopathy
4. Hepatic encephalopathy symptoms
5. Diagnostics
6. Hepatic encephalopathy treatment
7. Potential consequences and complications
8. Forecast
9. Prevention

Hepatic encephalopathy is a toxic lesion of the central nervous system that develops against the background of severe liver failure and manifests itself in neurological and endocrine disorders, depression, decreased intelligence, and personality changes.

Hepatic encephalopathy often develops against the background of chronic liver disease. According to statistics, it is observed in about 60% of patients with liver cirrhosis and is the main cause of persistent disability. Currently, in developed countries, there is an increase in the number of patients with chronic liver diseases. In this regard, questions concerning the pathogenesis, clinical picture, diagnosis and treatment of hepatic encephalopathy, the study of which will reduce mortality in this condition, are very relevant.

Source: moyagolova.ru

Forms of the disease

Depending on the etiological factor, several types of hepatic encephalopathy are distinguished:

• type A - due to acute liver failure;
• type B - caused by the ingestion of neurotoxins from the intestine into the bloodstream;
• type C - associated with liver cirrhosis.

According to the rate of increase in symptoms, hepatic encephalopathy is divided into two forms:

• acute - develops rapidly, accompanied by severe mental disorders;
• chronic - symptoms grow slowly, over months, and sometimes even years.

Causes and risk factors

The reasons for the development of hepatic encephalopathy associated with acute liver failure are:

• alcoholic hepatitis;
• acute viral hepatitis;
• liver cancer;
• diseases and intoxication, including drugs, accompanied by massive death of liver cells (hepatocytolysis).

Prolonged consumption of protein foods in excessive amounts, as well as active increased reproduction of obligate intestinal microbial flora, can lead to the ingestion of intestinal neurotoxins into the vascular bed.

Cirrhosis of the liver is manifested by the replacement of liver cells with connective (scar) tissue, which eventually leads to inhibition of all liver functions.

The factors that can trigger the pathological process of hepatic encephalopathy are:

• surgical interventions;
• infectious diseases;
• abuse of protein foods;
• chronic constipation;
• abuse of alcoholic beverages;
• gastrointestinal bleeding;
• overdose of certain drugs (drugs, diuretics, tranquilizers);
• development of peritonitis against the background of ascites.

With liver failure, the body changes hydrostatic and oncotic pressure, water-electrolyte balance, acid-base balance. Such changes have a negative effect on the functioning of the main nerve cells in the brain - astrocytes. This is due to the fact that these cells control the entry of neurotransmitters and electrolytes into the cells of the central nervous system, neutralize toxins, and regulate the permeability of the blood-brain barrier.

With liver failure, the concentration of ammonia in the blood increases, which, acting on astrocytes, disrupts their functions, as a result of which the production of cerebrospinal fluid increases, and, consequently, intracranial pressure increases, and cerebral edema develops. Apart from ammonia, astrocytes are also negatively affected by amino acids, fatty acids, false neurotransmitters, and under-oxidized breakdown products of fats and carbohydrates.

Stages of hepatic encephalopathy

There are four stages in the development of hepatic encephalopathy.

1. Subcompensated (initial) stage. The patient becomes apathetic, indifferent to the environment, or, conversely, his anxiety grows. Jaundice intensifies, body temperature may rise to subfebrile values.
2. Decompensated stage. The patient responds inadequately to events, irritable, can be aggressive. He has rapid flexion and extension movements in the wrist and metacarpophalangeal joints (flapping tremor), constant sleepiness during the day and insomnia at night.
3. Terminal stage. The patient is inhibited, in order to come into contact with him, he must be "stirred up", shouted loudly. The reaction to painful stimuli is preserved. In some cases, maladaptive behavior is observed (refusal of treatment and food, aggression, irritability, loud screaming).
4. Comatose stage. Movement, reaction to tactile and painful stimuli are absent. Pupils stop responding to light. Convulsive seizures appear. At this stage of hepatic encephalopathy, death occurs in 90% of patients.

Table. Stages of hepatic encephalopathy:

Stage	State of consciousness	Intellectual status	Behavior	Neuromuscular functions
0 (latent)	Not changed	Decreased concentration and memory (detected with targeted research)	Not changed	Increased execution time for psychometric functions
I	Disorientation, disturbance of the rhythm of sleep and wakefulness	Decreased ability for logical attention, counting	Depression, irritability, euphoria, anxiety	Tremor, hyperreflexia, dysarthria
II	Somnolence	Disorientation in time, a sharp decrease in the ability to count	Apathy, aggression, inappropriate responses to external stimuli	Asterixis, severe dysarthria, hypertonicity
III	Sopor	Disorientation in space, amnesia	Delirium, primitive reactions	Asterixis, nystagmus, rigidity
IV	Coma	-	-	Atony, areflexia, lack of response to pain

Hepatic encephalopathy symptoms

Signs of hepatic encephalopathy are mental and neurological disorders:

• behavioral disorders (apathy, indifference, euphoria, irritability);
• monotony of speech;
• sleep disturbances (insomnia at night and irresistible drowsiness during the day);
• intellectual disabilities (writing disorders, absent-mindedness, forgetfulness);
• disorders of consciousness (fixed gaze, lethargy followed by transition to stupor, and then coma).

As the liver failure increases, the metabolism of the waste products of the intestinal microflora (mercaptans) in the liver is disrupted. As a result, they begin to be excreted from the body through the respiratory tract and skin. Clinically, this is manifested by a characteristic sweetish "liver" smell.

In many patients, hepatic encephalopathy is manifested by arrhythmic large-sweeping asymmetric twitching of the muscles of the neck, trunk and extremities (hepatic tremor, asterix) arising at the time of tonic tension. Its appearance indicates a lesion of the cerebellum.

Damage to the center of thermoregulation is manifested by hypothermia or hyperthermia, and sometimes by alternating episodes of increased and decreased body temperature.

Endocrine symptoms of hepatic encephalopathy include:

• decreased sex drive;
• impotence;
• infertility.

Diagnostics

In the diagnosis of hepatic encephalopathy, a correctly collected anamnesis (indication of taking hepatotoxic medications, alcohol abuse, transfer of viral hepatitis) is of no small importance. When conducting a medical examination, special attention is paid to identifying signs of mental disorders and neurological symptoms. If a patient with hepatic coma has symptoms suggestive of brain stem damage, this is an extremely unfavorable prognostic sign.

Laboratory methods for diagnosing hepatic encephalopathy include:

• a general blood test - an increase in the number of leukocytes with toxic granularity of neutrophils, a decrease in platelets, erythrocytes, hemoglobin levels;
• coagulogram - a violation of the protein-synthesizing function of the liver becomes the cause of coagulopathy deficiency, which, as the patient's condition worsens, turns into DIC syndrome;
• biochemical blood test - an increase in the level of bilirubin, the activity of transaminases, alkaline phosphatase, gamma-glutamate transpeptidase.

If indicated, other types of laboratory tests are performed, the results of which in hepatic encephalopathy indicate the development of multiple organ failure.

In order to determine the degree of liver damage, the following are performed:

• magnetic resonance imaging of the liver and biliary tract;
• Ultrasound of the liver and gallbladder;
• computed tomography of the biliary tract;
• puncture biopsy of the liver.

To assess the state of the brain, electroencephalography (EEG) is performed.

Hepatic encephalopathy must be differentiated from other pathological conditions leading to extrahepatic damage to the central nervous system:

• post-convulsive, drug and alcoholic encephalopathy;
• increased nitrogen in the blood, not associated with hepatic causes;
• metabolic disorders;
• neuroinfection;
• intracranial catastrophe (rupture of cerebral aneurysm, hemorrhage in the cerebral ventricles, hemorrhagic stroke).

Hepatic encephalopathy treatment

Therapy of liver failure should be started by eliminating the cause that caused it (stopping gastrointestinal bleeding, therapy of infectious diseases, stopping the intake of hepatotoxic drugs or drinking alcohol). The complex treatment regimen includes bowel cleansing, lowering nitrogen levels, diet therapy, symptomatic measures.

The patient is prescribed a diet low in protein (no more than 1 g / kg / day) and table salt for a long time. If necessary, amino acid preparations are used.

Source: online.org

Regular bowel cleansing promotes the elimination of excess ammonia, thereby reducing its negative effect on the state of the nervous system. For this purpose, cleansing enemas are prescribed, taking lactulose, zinc sulfate, ornithine preparations.

Treatment of hepatic encephalopathy includes the appointment of oral forms of broad-spectrum antibiotics with low resorptive capacity (vancomycin, neomycin, kanamycin), which suppress the vital activity of the intestinal microflora.

When sedation is required, haloperidol is preferred. The appointment of benzodiazipine tranquilizers in hepatic encephalopathy is undesirable.

Potential consequences and complications

Hepatic encephalopathy is often accompanied by the development of various complications, among which the most common are:

• accession of a secondary infection;
• bleeding;
• pancreatitis;
• aspiration pneumonia;
• swelling of the brain.

Forecast

The prognosis for hepatic encephalopathy is generally poor. At the I-II stage of the disease, the mortality rate reaches 35%, and at the III-IV stage, it exceeds 80%. The survival rate is slightly higher among patients with chronic hepatic encephalopathy. In patients with cirrhosis of the liver, factors that worsen the prognosis are:

• hypoproteinemia;
• ascites;
• jaundice.

The most unfavorable course of acute hepatic encephalopathy is characteristic of patients under 10 and over 40 years of age, as well as in the case of its development against the background of low serum protein content, jaundice and viral hepatitis.

Prevention

Prevention of hepatic encephalopathy includes the following measures:

• a healthy lifestyle (good nutrition, refusal to drink alcohol);
• timely detection and active treatment of liver diseases;
• limiting the intake of drugs with hepatotoxic effects.

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Elena Minkina Doctor anesthesiologist-resuscitator About the author

Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.

Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.

The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!