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Hepatic Encephalopathy

The diagnosis is certainly a mouthful and comes with a lot of syllables, but more simply put, Hepatic Encephalopathy (HE) is an abrupt or chronic decline in brain function due to liver failure.

There is some good news though -- while it does cause some pretty dramatic neuropsychiatric abnormalities, it can be reversed through a variety of treatments based on the underlying cause. Hint: it's not always related to alcohol or viral hepatitis. For example, Non-alcoholic fatty liver disease also known as NASH is on a precipitous rise in this country. It is very progressive and can be equally as dangerous as the other etiologies mentioned above.

In a healthy individual (free from disease) nitrogenous waste products produced by our gut bacteria are either excreted through stool or urine - these are known endpoints of metabolism. Some of the nitrogen is also taken to the liver to be metabolized. However, in cirrhotic livers or in patients with liver failure this normal metabolic process is slowed or even halted all together - leading to a systemic circulatory increase of a toxic nitrogen contained compound - AMMONIA (NH3). Ammonia is not the entire story though. Other neurotoxins can cross the blood/brain barrier as well. Many times, this HE condition is both chronic and recurs many times over the patient's life and requires multiple hospital admissions.

Causes can be as a direct consequence of liver failure - usually acute, but other causes are possible. The other causes usually have a triggering event associated with them.

+Excessive Nitrogen load - from renal failure or GI bleeding

+Metabolic disturbances - think electrolyte derangements

+Drugs - benzos and NSAIDS are very common

+Infections - sepsis is extremely dangerous for many reasons

+Surgery - especially those procedures aimed at treating portal hypertension

Clinical manifestations can vary from mild confusion, to ataxia, incoherent speech, tremors and even a comatose state.


Treatment is aimed at reversing the underlying causes.

+Replacing electrolytes and restoring volume status

+Giving lactulose to bind and help remove the ammonia - promoting bowel movements

+Treating the infections

+Reduction of cerebral edema

+Promoting healthy gut bacteria in form of probiotic administration

+Fixing malnutrition - which is severely underdiagnosed

+Try to avoid sedative medications when possible - remember they are somnolent from the start -- that's part of their problem

March 11, 2024

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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