Hepatic encephalopathy (HE)

Hepatic encephalopathy (HE) is a condition that occurs when the liver is unable to adequately remove toxins from the blood, leading to a buildup of these toxins in the brain. The liver normally detoxifies harmful substances like ammonia, but when it's damaged or diseased (often due to cirrhosis or liver failure), these toxins can affect brain function.

Key points about hepatic encephalopathy:

1. Causes:

   • Liver disease: Chronic liver conditions like cirrhosis, hepatitis, or alcoholic liver disease are the primary causes.

   • Ammonia buildup: Ammonia, a waste product of protein digestion, is usually converted into urea by the liver. If the liver is impaired, ammonia can accumulate and affect the brain.

   • Other triggers: Infection, gastrointestinal bleeding, dehydration, kidney failure, medications (e.g., sedatives), and high-protein diets can worsen HE.

2. Symptoms:

   • Mild to severe cognitive impairment: Initially, patients may experience confusion, forgetfulness, or personality changes. In severe cases, they may have difficulty concentrating, respond abnormally to stimuli, or become disoriented.

   • Altered consciousness: In advanced stages, patients can experience drowsiness, confusion, or even coma.

   • Motor dysfunction: Fine motor skills may be impaired, such as hand tremors (a sign known as "asterixis").

   • Mood changes: Irritability, agitation, or apathy may also occur.

3. Diagnosis:

   • Clinical examination: Doctors will assess mental status and liver function.

   • Blood tests: Elevated ammonia levels can be an indicator, but they don’t always correlate directly with HE severity. Liver function tests (LFTs) will also be performed.

   • Neuropsychological testing: Sometimes, more detailed testing is used to assess cognitive function.

4. Treatment:

   • Treat the underlying liver disease: Improving liver function (if possible) or managing the liver disease is key.

   • Lowering ammonia levels: Lactulose is commonly used to reduce ammonia in the blood. It works by helping the body excrete ammonia through the stool.

   • Antibiotics: Rifaximin can be used to reduce the production of ammonia by gut bacteria.

   • Nutritional support: Since protein intake can contribute to ammonia buildup, managing diet is important, but protein should not be overly restricted, as it can lead to malnutrition.

   • Other supportive care: Electrolyte balance, treatment of infections, and avoidance of sedatives can help manage HE.

5. Prevention:

   • Control underlying liver disease: Preventing liver failure or managing cirrhosis can help reduce the risk.

   • Medication adherence: Ensuring patients take medications as prescribed to control ammonia levels and manage liver disease is essential.

   • Avoid triggers: Avoiding infections, gastrointestinal bleeding, and excessive protein intake can reduce the risk of episodes.

Hepatic encephalopathy can be reversible with timely treatment, but if left untreated or if liver function is severely compromised, it can lead to permanent brain damage or even death.