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HEPATIC ENCEPHALOPATHY

Marvelous Negbenebor

Jennifer Oduh

Okwuchi Ohanele

Ayoola Abimbola

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MODERATOR; DR DAVID S.O.

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CONTENTS

  • Introduction
  • Epidemiology
  • Precipitants
  • Pathogenesis
  • Classification/Grading
  • Clinical features
  • Investigation
  • Treatment
  • Prevention
  • Prognosis
  • Conclusion

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Hepatic Encephalopathy

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INTRODUCTION

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  • Hepatic encephalopathy is a debilitating manifestation of a liver disease especially liver cirrhosis
  • Liver diseases have a general effect on the whole body but very notably is it's effect on the brain
  • It causes a spectrum of symptoms ranging from cognitive impairment to coma.

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DEFINITION

  • Hepatic encephalopathy is defined as a neurological dysfunction caused by liver insufficiency
  • Hepatic encephalopathy is a neuropsychiatric syndrome caused by liver disease

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CONTD

  • Hepatic encephalopathy once present is a poor prognosis of the underlying liver disease.
  • And unless the cause of the encephalopathy is properly treated, it poses a risk of recurrence.

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EPIDEMIOLOGY

  • The exact epidemiology of hepatic encephalopathy is not known
  • 64 patients were studied comprising, 43 (67.2%) out-patients and 21 (32.8%) in-patients.
  • The age of the patients recruited for the study ranged from 20 to 90 years.

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EPIDEMIOLOGY CONTD

  • The highest number of patients was within the age range of 30–49 years (65.6%) with a male to female ratio of 4.8:1.
  • Majority of the patients had a form of formal education (70.3%) while the remaining (29.7%) patients had no formal education

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EPIDEMIOLOGY CONTD

  • In the United States, Hepatic Encephalopathy patients account for about 110,000 hospitalizations yearly.
  • Patients with previous bout of Hepatic Encephalopathy have a 40% risk of recurrence in 1year
  • Trends over the past 10 years suggests that the burden of hepatic encephalopathy is increasing.

Hepatic Encephalopathy

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EPIDEMIOLOGY CONTD

  • Encephalopathy is seen in 30-45% of liver cirrhosis patients
  • It is also observed in 24-53% of patients that have Undergone portosystemic Shunt surgery
  • Subtle signs of hepatic encephalopathy is seen in 70% of patients with Liver cirrhosis

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EPIDEMIOLOGY CONTD

• The risk for the first bout of Hepatic Encephalopathy is 5%-25% within 5 years after cirrhosis diagnosis

• And it depends on the presence of risk factors (such as infections, variceal bleeding, ascites, hepatitis)

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Hepatic Encephalopathy

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EPIDEMIOLOGY CONTD

  • An hospital based study in West Sudan found out that the common complications of liver cirrhosis were
    1. Ascites (92%)
    2. Hepatic encephalopathy (19%)
    3. Portal hypertension (8%)
    4. Hepatocellular carcinoma (5%)
    5. Spontaneous bacterial peritonitis (3%)

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Hepatic Encephalopathy

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PRECIPITANTS OF HEPATIC ENCEPHALOPATHY

  • Large protein meals
  • Constipation
  • Portosystemic Shunting
  • Gastrointestinal bleeding
  • Medications
  • Diuretic Therapy
  • Renal failure
  • Infection
  • Dehydration/ Hypovolemia
  • Hypokalaemia

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PATHOGENESIS

  • Hepatic encephalopathy occurs as a result of a disturbance of brain function provoked by circulating neurotoxins that are normally metabolized by the liver.

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  • Key factors responsible for this include:

-Liver dysfunction

-Portosystemic shunting

-Decreased clearance of ammonia

-Increased ammonia uptake by brain

-Neurotransmitter imbalance

-Brain oedema

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Other molecules involved include;

  • Mercaptans
  • Short chain fatty acids
  • Phenols

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PATHOGENESIS CONTD

  • Brain cells (astrocytes) from a 51 year old alcoholic patient with cirrhosis who died in a coma.
  • The image shows normal astrocytes (N), which lack dark nuclei, and Alzheimer type II astrocytes (Alz), characteristic of HE, which have pale enlarged nuclei.

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CLASSIFICATION OF HEPATIC ENCEPHALOPATHY

  • Classification according to the underlying disease, HE is subdivided into;
    • Type A resulting from Acute liver failure
    • Type B resulting predominantly from portosystemic shunting
    • Type C resulting from cirrhosis

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CLASSIFICATION OF HE CONTD

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CLASSIFICATION CONT’D

  • According to its time course, HE is subdivided into
    • Episodic HE
    • Recurrent HE denotes bouts of HE that occur with a time interval of 6 months or less.
    • Persistent HE denotes a pattern of behavioral alterations that are always present and interspersed with relapses of overt HE.

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CLASSIFICATION CONT’D

According to the existence of precipitating factors, HE is subdivided into

    • Nonprecipitated or
    • Precipitated, and the precipitating factors should be specified.
    • Precipitating factors can be identified in nearly all bouts of episodic HE type C and should be actively sought and treated when found.

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Based on severity of manifestation

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CLINICAL FEATURES OF HE

  • Asterixis
  • Fetor hepaticus may be present
  • Hyperventilation
  • Decreased body temperature
  • Stigmata of chronic liver disease : parotid swelling, dupuytrens contracture, koilonychia, leuconychia, palmar erythema, finger clubbing, spider nevi

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CLINICAL FEATURES OF HE CONTD

  • Dilated anterior abdominal wall veins
  • Features of anemia
  • Edema
  • Hyper-reflexia, Parkinsonian syndromes.

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DIAGNOSIS OF HE

  • The diagnosis of hepatic encephalopathy is a clinical one, once other causes of confusion or coma have been excluded

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DIAGNOSTIC CRITERIA FOR HE

  1. Presence of liver disease, acute or chronic, with or without portosystemic shunting
  2. Disturbance of mentation and awareness
  3. Shifting combination of neurological signs and symptoms.
  4. Delta waves of 3 spikes seen on EEG

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INVESTIGATIONS

  • Haemotology:
    • Thrombocytopenia (+ prolonged clotting time)
    • Leucopenia
    • Pancytopenia
    • Platelet
    • Anaemia

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INVESTIGATIONS CONT’D

  • Biochemical
    • LFT : mild increase in liver enzymes ALT, total bilirubin, L-phenylalanine
    • Electrolyte( hyponatremia, hypokalemia) , urea(hyperammonia), creatinine
    • Hypoproteinemia, hypoalbuminemia, hypoglycemia, hypocholesterolemia,

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INVESTIGATIONS CONT’D

    • Viral Screening

- HIV, HBV, HCV

    • CSF analysis

-Increased glutamate, glutamine, phenylalanine, tyrosine and tryptophan

    • Urinalysis
    • Paracentesis for SBP
    • Toxicology

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INVESTIGATIONS CONT’D

  • Imaging
    • Endoscopy ( esophageal varices)
    • Abdominal ultrasonography : features of portal hypertension (splenomegaly , collateral vessels), liver disease (nodules, portal vein thrombosis)
    • CT scan : cerebral edema, tumour, hemorrhage, abscess, widening of sulci
    • MRI angiography ( to see the extent of portal vein thrombosis, portosytemic shunt, etc

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INVESTIGATIONS CONT’D

  • Others
    • Measurement of portal venous pressure
    • Neuropsychometric test
    • Electroencephalography

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Treatment

  • Identify and remove the precipitating factors
  • Give purgatives to empty the bowels of nitrogenous substances e.g Lactulose
  • Give antibiotics e.g Rifaximin, Metroinidazole
  • Adequate nutrition and hydration

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Prevention

• Avoid alcohol

• Avoid medications that affect the nervous system such as antidepressants

• Eat a nutritious diet and exercise

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Complications

  • The complications are;
  • Hepatorenal syndrome
  • Portal hypertension
  • Hepatocellular carcinoma
  • Permanent brain damage

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Prognosis

  • Varies, but if picked early it is reversible

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  • Differential diagnosis
  • Wernicke's Encephalopathy
  • Hypertensive Encephalopathy
  • Uremic Encephalopathy
  • Cerebrovascularaccident
  • Delirium secondary to illicit drugs
  • Alcohol withdrawal and intoxication

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Conclusion

  • Hepatic encephalopathy is a diagnosis of exclusion
  • All cirrhotic patients hospitalized for HE should be evaluated for a precipitating factors
  • If HE is detected early, can be reversible

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REFERENCE

  • Sharma, K., Akre, S., Chakole, S., & Wanjari, M. B. (2022). Hepatic Encephalopathy and Treatment Modalities: A Review Article. Cureus, 14(8), e28016. https//doi.org/10.7759/cureus.28016
  • Hepatic Encephalopathy Mina Shaker, MD William D. Carey, MD Published: June 2014 Last Reviewed: August 2017( Cleveland clinic) http//www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/hepatic-encephalopathy/

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REFERENCE

  • Davidson’s Principles and Practice of Medicine, 22nd Edition
  • Medscape
  • PubMed Central

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THANK YOU

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