Hepatic encephalopathy

DR. Prof. Balvir Singh(MBBS. M.D. Medicine ,MNAMS,FICP,FIACM)

Hepatic encephalopathy

Hepatic encephalopathy is a neuropsychiatric syndrome caused by hepatic insufficiency

It represents a reversible decrease in neurologic function, based upon the disorder of metabolism which are caused by severe decompensated liver disease

“Portal-systemic encephalopathy” - patients with portal hypertension abnormal shunting of blood

It occurs most often in patients with cirrhosis but also occur in acute hepatic failure.

Causes: Chronic parenchymal liver disease:

Chronic hepatitis: Cirrhosis.

 Fulminating hepatic failure: Acute viral hepatitis Drugs Toxins e.g. Wilson’s Disease, CCL4,

Surgical Portal-systemic anastomoses, - portacaval shunts, or Transjugular intrahepatic portal-systemic shunting [TIPS]).

Factors precipitating hepatic encephalopathy:

Metabolic stress Infection Electrolyte imbalance, especially hypokalemia; Dehydration , Renal failure Diuretic drugs,

Disorders that increase gut protein GI bleeding High-protein diet

Nonspecific cerebral depressants alcohol, sedatives, analgesics

PATHOPHYSIOLOGY

Clinical Features of hepatic encephalopathy:

A Disturbance in consciousness Disturbances in sleep rhythm. Impaired memory/ apraxia Mental confusion. Apathy. Drowsiness / Somnolence  Coma.

B. Changes Personality Childish behavior. May be aggressive out burst. Euphoric. Foetor hepaticus – Foul–smelling

breath associated with liver disease due to mercaptans

C Neurological signs: Flapping tremor / Asterixis (in

pre coma). Exaggerated tendon reflex. Extensor plantar reflex.

Clinical stages of Hepatic Encephalopathy

InvestigationsDiagnosis is usually made clinically No Pathognomonic liver function

abnormality Elevation of blood ammonia Hypokalaemia EEG (Electroencephalogram) CSF & CT Scan – Normal Other Routine Investigations - TC,

DC, ESR, Hb, Na, k, Urea, Creatinine, Prothrombin time

Differential DiagnosisSubdural HaematomaDrug or Alcohol intoxicationWernicke’s encephalopathyHypoglycaemia