Liver encephalopathy is a cardinal feature of fulminant hepatic failure which is as a result of massive necrosis of liver cells or any other severe impairment of liver function.
Precipitating Factors for Liver Encephalopathy
- Gastrointestinal bleeding.
- High protein diet.
- Constipation.
- Infection.
- Any procedure (paracentesis, surgery).
- Excessive diuretics causing hyponatremia, hypokalaemia and renal failure.
- Sedatives and hypnotic drugs.
- After surgical porto-systemic shunts.
Pathogenesis Of Encephalopathy
- A few theories are given to explain the cause of liver encephalopathy.
- Direct neurotoxicity.
- Toxic substances (including ammonia, amines and indole) normally detoxified by the liver enter the systemic circulation and thus the brain where they alter cerebral metabolism.
- Toxic substances (including ammonia, amines and indole) normally detoxified by the liver enter the systemic circulation and thus the brain where they alter cerebral metabolism.
- Inhibition of neural function.
- One or more of these metabolites may cross the blood brain barrier and promote inhibition of neurons thus-
- There is accumulation of false neurotransmitters in brain which are formed by bacterial action in colon.
- There is alteration in ratio of amino acids.
- GABA- is a principle inhibitory neurotransmitter of brain. It can be synthesized by gut bacteria and may bypass the liver due to grossly damaged liver cells.
- One or more of these metabolites may cross the blood brain barrier and promote inhibition of neurons thus-
- Other factors.
- Which can contribute to causation or deterioration of hepatic encephalopathy include hypoglycemia episodes, alkalosis and hypokalaemia.
Stages Of Hepatic Encephalopathy
- Prodromal stage.
- In the early phase, patient shows signs of impaired memory, confusion, irritability and lack of concentration.
- In the early phase, patient shows signs of impaired memory, confusion, irritability and lack of concentration.
- Impending coma.
- In this phase, there is clear cut mental confusion, speech is often slurred, patient sleeps most of the time but can be aroused. This phase is characterized by flapping tremors of outstretched hands (asterixis) and characteristic sweet smell of ‘foetor hepaticus’ in breath.
- Coma.
- This phase is characterized by dilated pupils, rapid and deep inspirations, wavy posture and terminal hyper-pyrexia.
- Liver encephalopathy is associated with other signs of liver failure like jaundice, gastrointestinal bleeding, cerebral edema, renal failure and electrolyte disturbances.
Clinical Grading Of Liver Encephalopathy
- Grade I- euphoria, occasionally depression, mild confusion, speech problems, sleep rhythm disorder.
- Grade II- drowsy, but responding to simple commands and inappropriate behavior.
- Grade III- sleeps most of the time, but arousable. Marked confusion and incoherent speech.
- Grade IV- unarousable.
- Grade V- coma unresponsive to painful stimuli.
Management Of Liver Encephalopathy
Elimination or control of precipitating factors.
- Monitoring of fluid, electrolyte and glucose levels.
- Elimination of diuretics if it contributes to imbalance.
- Search for focus of infection.
- Reduction of nitrogenous materials in bowels should be achieved. This can be achieved by protein free diet- fruits juices, coconut water, vegetable soups, glucose, and sucrose solution.
- Bowel wash daily.
- Colonic wash with 2-4 gm neomycin added to lactose or mannitol.
- Lactose can be given orally to acidify the colon to obtain 2-3 soft stools a day.
- In country, with its high prevalence of intestinal lactase deficiency, lactose is cheaper alternative.
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