What is hepatic encephalopathy

Hepatic encephalopathy is a complex of neurological and mental disorders resulting from toxic damage to the central nervous system due to acute liver failure.

Treatment of hepatic encephalopathy is carried out exclusively in a hospital setting, since this is a serious medical problem that requires the intervention of professional doctors.

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Description of pathology

In the international classification of diseases ICD 10, hepatic failure is assigned the code K72, and the code G93.4 is assigned to encephalopathies, the etiology of which is not specified.

Let’s figure out what hepatic encephalopathy is. This disease develops in liver pathologies relatively rarely. Most of the diagnosed cases are complications of chronic liver diseases, accompanied by insufficient functionality of this organ. The pathophysiology of the process is currently not fully understood.

Experts who study liver diseases have noticed such an interesting relationship: if a person develops acute hepatic encephalopathy against the background of liver failure, then the risk of developing cirrhotic processes in the future is minimal.

Causes of liver encephalopathy

This pathology can complicate the course of almost any type of liver failure and diseases of this organ.

The reasons for the development of the disease include:

  • cirrhosis and other diffuse organ lesions,
  • various intoxications of the body, which have a negative effect on the functionality of the organ,
  • acute obliterating processes leading to stagnation (neoplasms, metastases),
  • provoking factors of external influence (severe burns, painful shock, sepsis, hemorrhages and other reasons).

Most often, encephalopathy develops against the background of such diseases as severe inflammation of the liver of viral etiology, intoxication with plant and industrial toxic substances, uncontrolled intake of potent drugs. In such cases, the rapid development of pathology is noted, immediate medical attention is needed.

Hepatic encephalopathy with cirrhosis of the liver or damage to this organ by cancerous metastases develops gradually, the symptoms can grow rather slowly.

In addition to the direct causes of brain intoxication with toxic substances against the background of liver failure, doctors identify a number of provoking factors. These include:

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  • alcohol addiction,
  • excessive consumption of protein foods,
  • uncontrolled treatment with diuretics,
  • acute infectious or chronic concomitant diseases,
  • internal bleeding in the organs of the digestive tract,
  • violations of acid-base balance,
  • general anesthesia.

There is a very high probability of developing encephalopathy with liver cirrhosis, exacerbations of chronic hepatitis.

Pathogenesis of the disease

If a person is diagnosed with such a serious condition – hepatic encephalopathy, its pathogenesis includes several stages of development. The classification used today includes four stages of the disease.

At the first stage, the patient experiences a gradual depression of the cognitive functions of the brain, a decrease in concentration. Behavioral responses slow down. There is apathy, lack of interest in life.

There is a decrease in the intellectual level, sleep disorders. In some cases, with hepatic encephalopathy, excessive excitability is observed, sometimes turning into aggressiveness.

At the second stage of the development of pathology, there is an increase in the symptoms of the first phase of the disease. The aggressiveness of patients is becoming more and more pronounced. There is no logic in the actions performed. At this stage, a characteristic “flapping” tremor may appear.

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Signs of the third degree of pathology are expressed in serious impairments of consciousness. Periodic periods of complete stupor may occur. The damage to the brain by toxins is so serious that the patient does not control the processes of defecation and urination.

Convulsive phenomena, decreased sensitivity to external influences, decreased tone of the muscle corset are observed. At this stage, there is an ammoniacal odor from the patient’s mouth.

The fourth stage of the pathology is considered terminal. If the disease progresses to this degree, death is predicted in more than 80% of cases. Patients experience suppression of all vital functions.

This condition is called hepatic coma. The reflective activity of the brain centers in this state is minimal. Sometimes the patient wakes up. In consciousness, he shows all the same aggressiveness, since he is tormented by pain. There may be a lack of reaction of the pupil to light, relaxation of the ocular sphincter.

clinical picture

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The syndrome of signs of hepatic encephalopathy includes both neurological and mental disorders. Symptoms increase with the progression of the pathology and the intensification of intoxication of the tissues of the central nervous system with metabolic decay products.

The clinical picture changes depending on the stage of development of the disease.

In the early stages of pathology, there is a decrease in the intellectual level of patients, the speed of behavioral reactions, a change in the daily routine, sleep disorders, and increasing irritability.

As the disease progresses, pathological drowsiness, impaired coordination of movements, and speech disorders are noted. The patient begins to find it difficult to navigate in space and time, is not aware of himself, his actions and actions become meaningless.

At the terminal stage of the development of the pathological condition, the patient is completely disoriented, the body functions are depressed, coma and death occur.

Diagnosis of pathology

The primary diagnosis of hepatic encephalopathy is carried out on the basis of anamnestic data, a study of the clinic of the current pathology. Also, specially developed diagnostic tests are used to determine the psychomotor functions of the patient’s body.

A well-known number correlation test is used to diagnose and detect encephalopathy in the setting of liver failure. To pass it, the patient needs to connect in order of number in a certain time. A person whose liver cannot cope with its main function – cleansing the body – needs more time to pass the test.

This suggests that the concentration of attention and the speed of reactions are reduced in comparison with the indicators of healthy people, in whom no toxic damage to brain tissue by metabolic decay products has been recorded.

General and biochemical blood tests are prescribed. A puncture of the liver tissue is mandatory to assess the degree of organ damage and to find out its cause. Also, the patient is assigned to such studies as ultrasound of the affected organs, CT and MRI. The degree of damage to the central nervous system is assessed using an electroencephalogram.

At an early stage of pathology, differential diagnosis is rather difficult. But with more pronounced symptoms characteristic of the later stages of the development of encephalopathy, the disease must necessarily be differentiated from intracerebral hemorrhages, rupture of a vascular aneurysm, and infectious processes in the brain.

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Potential causes of encephalopathy that are not associated with liver failure, but that cause an excess of the permissible level of ammonia and nitrogenous compounds in the body are considered. It is also necessary to exclude alcoholic, drug and other intoxicating encephalopathies.

Treatment

If a patient is diagnosed with hepatic encephalopathy, then its symptoms and the prescribed treatment depend on the degree of development of hepatic failure. Therapeutic methods are aimed at eliminating the underlying disease, the root cause of encephalopathy.

In the treatment of encephalopathy against the background of liver failure, doctors adhere to several principles:

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  • elimination of the causes of the development of liver failure,
  • restoration of the normal level of essential amino acids,
  • detoxification of the body from ammonia and nitrogenous compounds,
  • dietary food with limited protein,
  • drug acceleration of ammonia utilization.

For the quickest removal of ammonia from the body, drugs are used, which include lactulose. For the same purpose, patients are advised to empty their bowels at least twice daily.

Special enemas are also performed to cleanse the intestines. Lactulose is used as a laxative. The drug lactulose stimulates the smooth muscles of the intestines for better bowel function.

In addition, lactulose has a depressing effect on the vital activity of the pathogenic intestinal microflora. Also, the drug lactulose promotes better absorption of electrolytes and the elimination of ammonium salts.

If liver failure is a consequence of infectious processes, antibacterial drugs and non-steroidal anti-inflammatory drugs are used. Droppers are placed daily to maintain body functions and restore metabolic processes.

Patients are shown a special diet with reduced intake of protein products. Such a diet helps restore liver function and eliminate protein overload.

The third and fourth stages of pathology are characterized by the patient’s grave condition, insufficient functionality of all organs and systems of the body, as well as a high probability of dangerous complications, therefore, therapy is carried out in the intensive care unit of the clinic.

Among the most dangerous complications of hepatic encephalopathy are: cerebral edema, pneumonia due to aspiration, severe inflammation of the pancreas.

In some cases, medications are ineffective, the liver is destroyed so much that the pathological processes occurring in it become irreversible. It is impossible to treat such patients without the use of surgical intervention. In such cases, liver transplantation may help the patient to some extent.

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Tatyana Jakowenko

Editor-in-chief of the Detonic online magazine, cardiologist Yakovenko-Plahotnaya Tatyana. Author of more than 950 scientific articles, including in foreign medical journals. He has been working as a cardiologist in a clinical hospital for over 12 years. He owns modern methods of diagnosis and treatment of cardiovascular diseases and implements them in his professional activities. For example, it uses methods of resuscitation of the heart, decoding of ECG, functional tests, cyclic ergometry and knows echocardiography very well.

For 10 years, she has been an active participant in numerous medical symposia and workshops for doctors - families, therapists and cardiologists. He has many publications on a healthy lifestyle, diagnosis and treatment of heart and vascular diseases.

He regularly monitors new publications of European and American cardiology journals, writes scientific articles, prepares reports at scientific conferences and participates in European cardiology congresses.

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