Hepatic Encephalopathy (HE): A Guide For Patients

What is Hepatic Encephalopathy (HE)?

Hepatic Encephalopathy (HE) is a complication that can occur when the liver is not working properly. The liver helps filter out toxins from the blood, but when it is damaged (like in cirrhosis or liver failure), toxins can build up in the body and enter the brain. This can lead to changes in behavior, thinking, and memory.

Causes of Hepatic Encephalopathy

HE often occurs in people with liver disease, especially cirrhosis (a scarring of the liver). The most common causes of HE include:

• Liver cirrhosis: Scarring of the liver due to long-term liver damage
• Liver failure: When the liver cannot function well enough to remove toxins from the blood
• It can be triggered by the following factors:
  • Gastrointestinal bleeding
  • Constipation
  • Infections
  • Dehydration (due to factors such as fluid restriction, diuretics, diarrhea, vomiting, or excessive paracentesis)
  • Electrolyte imbalances
  • Alcohol use disorder
  • Certain medications
  • Kidney dysfunction

Special Situations: Post-TIPS Hepatic Encephalopathy

What is Post-TIPS Encephalopathy?

After TIPS (a channel is created inside the liver to allow blood to flow more easily and reduce pressures), some blood bypasses the liver, meaning fewer toxins are removed. As a result, toxins can reach the brain more easily, leading to hepatic encephalopathy.

How Common is Encephalopathy After TIPS?

• About 30-40 out of 100 patients may develop HE after TIPS
• Most episodes occur within the first 3-6 months
• In many patients, symptoms are mild and treatable
• Only a small number develop severe or difficult-to-control HE

Who is at Higher Risk After TIPS?

The risk of HE after TIPS is higher in patients who:

• Had HE before TIPS
• Are older
• Have advanced liver disease
• Have poor kidney function
• Have low muscle mass or malnutrition

Symptoms of Hepatic Encephalopathy

The symptoms of HE can range from mild to severe. They may develop slowly, but in some cases, they can come on suddenly. Common signs include:

• Changes in thinking: Confusion, difficulty concentrating, or memory problems
• Behavior changes: Feeling agitated, irritable, or depressed
• Sleep problems: Feeling sleepy during the day or having trouble sleeping at night.
• Hand tremors: Shaking or twitching of your hands.
• Difficulty with balance and coordination: You might notice that it's harder to walk or keep your balance.
• Bad breath: This can develop because of toxins in the body.
• Personality changes: You or others may notice your mood or behavior changes

If these symptoms happen suddenly or worsen quickly, it is important to seek medical help right away.

How is Hepatic Encephalopathy Diagnosed?

If your doctor suspects HE, they may:

• 1. Review your medical history: They will ask about any liver disease, symptoms, or medications you're taking.
• 2. Physical exam: Your doctor will look for signs of liver disease and neurological changes (like tremors or confusion).
• 3. Blood tests: These help check for toxins in your blood and liver function.
• 4. Brain function tests: Sometimes, doctors use tests to check how well your brain is working, like the Number Connection Test or some more advanced tests.
• 5. Mobile Application based tests: Smartphone-based Stroop test (EncephalApp) can give an indication of the mental status
• 6. Imaging tests: Your doctor may use an ultrasound or CT scan to check for liver damage or other possible causes of symptoms.

Treatment for Hepatic Encephalopathy

Treatment for HE focuses on reducing the toxins in your blood and improving liver function. It often includes:

1. Medications:

• Lactulose: This is a common medication used to reduce the level of toxins (especially ammonia) in your blood. It helps to clear the toxins through stool.
• Antibiotics: Sometimes, antibiotics like rifaximin are used to reduce bacteria in your gut that produce toxins.

2. Treating the underlying cause: If you have an infection, bleeding, or another trigger, your doctor will treat it to help prevent HE from worsening.

3. Dietary changes:

• Protein management: You may need to adjust your protein intake. Too much protein can make HE worse by increasing the amount of ammonia your body produces. Your doctor or dietitian can help guide you on the right amount of protein to eat.
• Low-sodium diet: If you have liver disease, your doctor may also recommend a low-sodium diet to prevent fluid buildup.

4. Shunt blockage: In case of recurrent episodes of encephalopathy, you may be offered a procedure to block dilated vascular channels to prevent recurrence.

5. Liver transplant: In severe cases, when the liver is no longer able to function properly, a liver transplant might be considered.

What If Post-TIPS Encephalopathy Does Not Improve?

In a small number of patients with severe or recurrent HE post TIPS:

• The TIPS diameter may be reduced
• In rare cases, the TIPS may be partially or completely closed

Preventing Hepatic Encephalopathy

Here are some tips to keep a close check on the underlying liver disease to prevent the onset or worsening of HE:

• Avoid alcohol: Alcohol can make liver problems worse, so it's important to avoid drinking alcohol if you have liver disease.
• Eat a balanced diet: Follow your doctor's advice on protein intake and limit salt in your diet. Small, frequent meals may help if you have trouble eating.
• Ensure stools passage 2-3 times per day
• Monitor your symptoms: Keep track of any deterioration in your liver health (yellowing of the skin and eyes, excessive itching, bleeding from the stomach or intestines which can be seen in vomitus or stool, problems with blood clotting, increased abdominal girth etc) and let your doctor know.
• Watch for warning signs: If you notice sudden changes in your thinking, behavior, or ability to move, contact your doctor immediately.
• Take your medications as prescribed: It is important to follow your doctor's instructions about medications, especially lactulose, and to take them regularly.

When to Seek Medical Help

You should contact your healthcare provider if you notice:

• Sudden confusion or changes in behavior
• Severe drowsiness or difficulty staying awake
• Shaking or tremors that won't go away
• Problems with balance or coordination

Key Takeaways:

• Hepatic Encephalopathy (HE) is a condition that affects the brain when the liver is not functioning properly.
• It is a symptom of liver disease and can cause confusion, changes in behavior, and problems with coordination.
• Treatment involves medications, dietary changes, and managing the underlying liver disease.
• It's important to follow your treatment plan, watch for changes, and seek medical help if symptoms worsen.

If you ever have questions or notice symptoms getting worse, don't hesitate to contact your healthcare provider. They are there to help you manage HE and support your liver health.

Disclaimer: Some portions of this content may be derived from publicly available sources on the internet.