Hepatic encephalopathy

and Christiane Fux, medical editor

Christiane Fux studied journalism and psychology in Hamburg. The experienced medical editor has been writing magazine articles, news and factual texts on all conceivable health topics since 2001. In addition to her work for, Christiane Fux is also active in prose. Her first crime novel was published in 2012, and she also writes, designs and publishes her own crime plays.

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Hepatic encephalopathy is a disorder of the brain. The cause is an advanced liver disease, such as cirrhosis of the liver. The brain is increasingly poisoned by ammonia and other substances that accumulate in the blood. In mild cases, concentration disorders, mood swings or drowsiness are the result, in severe cases there is a risk of hepatic coma. Read more about signs, causes, and treatment here.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K74K76K70K71K72

How does hepatic encephalopathy arise?

The cause of a hepatic encephalopathy (also: portosystemic encephalopathy) is a severe dysfunction of the liver. One of the most important tasks of the organ is to break down toxins in the body. Sometimes, however, the liver is so damaged that it can no longer cope with this task - for example, if cirrhosis of the liver develops as a result of years of alcohol abuse or hepatitis. The liver tissue is then largely nodular and scarred and loses its function.

Increasing concentrations of pollutants in the blood

If the liver is no longer able to break down toxins into harmless components, the concentration of pollutants in the blood increases. This has serious effects on the whole body, especially on the central nervous system (CNS), especially the brain cells. Various substances are involved - above all ammonia, a breakdown product of various amino acids (building blocks of proteins).

Normally, the liver processes ammonia into non-toxic urea, which is excreted. If this mechanism is disturbed, more and more ammonia gets into the brain and causes certain brain cells - the so-called astrocytes - to swell. The pressure inside the brain increases. Thus, liver failure ultimately results in brain edema.

Hepatic encephalopathy: triggers

Acute liver failure due to viral infection or poisoning can also trigger acute hepatic encephalopathy. In this case, the liver functions perish within a few days.

Usually, however, the cause is a chronic liver disease to which other factors suddenly appear. In such cases it does not develop suddenly, but slowly and insidiously. This includes:

• Bleeding in the gastrointestinal tract
• high protein food
• Infections that lead to increased protein utilization
• Diarrhea, vomiting, or laxatives
• certain medications (such as sedatives)

Sometimes doctors treat cirrhosis of the liver with what is known as a portosystemic shunt, an artificial connection in the vascular system that ensures that the blood from the intestines, stomach and spleen is no longer collected and passed through the damaged liver. This can be useful before a liver transplant, for example. One possible side effect of this procedure is hepatic encephalopathy, as the blood is no longer filtered.

Hepatic encephalopathy: symptoms and stages

The swollen astrocytes change the concentration of various messenger substances in the brain and the nerve cells can no longer communicate properly. Therefore, the hepatic encephalopathy brings with it various neurological symptoms, which are divided into four stages and a preliminary stage depending on the severity.

Pre-stage (minimal hepatic encephalopathy)

In many cases, the first stage is preceded by a phase in which the hepatic encephalopathy shows hardly any symptoms. This is also called minimal hepatic encephalopathy. Usually only close relatives notice that something is wrong with the person concerned. Patients are sleepy and show a loss in

• concentration
• Short term memory
• visual-spatial perception
• Information processing
• Fine motor skills

Neurologically nothing can be determined here, but this stage can be uncovered with various psychometric tests such as number or drawing problems.

Warning: There is already an increased risk of accidents on the road!

Hepatic encephalopathy: stage 1

In the first stage, the symptoms are still comparatively mild.

• sleep disorders
• Mood swings
• euphoria
• slight confusion
• Difficulty concentrating
• Eye flutter

Hepatic encephalopathy: stage 2

With the help of electroencephalography (EEG), changes in brain waves can also be recorded from the second stage, which indicate hepatic encephalopathy. Otherwise amplification of symptoms from stage 1 as well

• Personality changes
• Disorientation
• fatigue
• Memory problems
• changed facial expressions (grimacing)
• rough trembling of the hands ("flapping tremor")

Hepatic encephalopathy: stage 3

The poisoning is well advanced and the symptoms are severe.

• Patient sleeps most of the time
• severe disorientation
• Flapping tremor
• indistinct speech

Hepatic encephalopathy: stage 4

The patient's condition deteriorates to the point of unconsciousness.

• Liver coma (hepatic coma)
• The patient can no longer be woken up, but still reacts to stimuli

While in acute liver failure the person concerned usually goes through the individual stages very quickly and can fall into a coma within days, hepatic encephalopathy in people with chronic liver failure only progresses slowly and gradually. Usually there is no pronounced brain edema in the course of the disease.

Chronic courses can be found especially in older people. In their "basic state" they usually only show mild neuropsychiatric symptoms. In between, acute phases with more pronounced symptoms occur.

Hepatic encephalopathy: treatment

Treatment for hepatic encephalopathy focuses on two factors: eliminating triggers and reducing ammonia formation.

Elimination of triggering factors

• Stopping a gastrointestinal bleeding Bleeding
• Deposition of drainage agents
• Narrowing of a liver shunt

Reduction of ammonia pollution

• Lactulose and Lacitol increase the acidity in the intestine, which reduces the absorption of ammonia from the intestine
• Taking an antibiotic that weakens the bacteria that produce ammonia.
• At least at times low-protein diet, especially meat and eggs. because when it is processed, ammonia is produced.

Further measures

The administration of the following substances can also improve the condition:

• Zinc prevents cell damage in the liver and helps to regenerate it.
• Ornithine aspartate accelerates the urea cycle, thereby reducing the ammonia content and thus improving brain functions.
• Branched-chain amino acids prevent the body from breaking down its own protein in order to compensate for a deficiency in it. This creates ammonia.

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