Hepatic encephalopathy

Diagnosis

Hepatic encephalopathy is diagnosed by looking at the medical history, signs and symptoms, medicine use, and the results of blood tests and other tests. Tests and procedures that may be used to diagnose acute liver failure include:

• Psychological exam. Tests that look for thinking skills may be used when symptoms are hard to detect, such as in covert hepatic encephalopathy. A test that involves naming animals is one such test.
• Neuropsychological tests. Tasks that involve the use of pencil and paper can be used to assess thinking, motor skills, speed and hand coordination. The Psychometric Hepatic Encephalopathy Score is one such test. Tests that check reaction time to sounds, such as the continuous reaction time test, also may be used.
• Blood tests. Blood tests for ammonia, electrolytes, glucose level, C-reactive protein and other markers can help rule out other conditions that have similar symptoms, such as diabetes and stroke. Blood tests also show whether infections or use of alcohol or medicines are a factor.
• Electroencephalogram, also called EEG. An EEG measures electrical activity in the brain. This helps healthcare professionals understand the severity of the condition.
• Imaging tests. A CT scan or MRI that looks at the liver and blood vessels may be done to rule out stroke, seizures or other causes. Scans of the gut area may show issues with liver blood flow.

Stages

The West Haven criteria are used to classify severity of disease. There are five grades, also called stages, of hepatic encephalopathy:

• Grade 0. There are no symptoms, and hepatic encephalopathy is found only by tests.
• Grade 1. Typical symptoms include sleep issues, mild confusion and mood swings.
• Grade 2. Disorientation and unusual behavior are common in grade 2. Daytime drowsiness also may be present.
• Grade 3. Extreme confusion and sleepiness are typical, though the person can still respond to others.
• Grade 4. A type of coma called hepatic coma is present, and the person cannot respond to others.

Grade 0 and grade 1 are known as covert hepatic encephalopathy because in these stages, the condition may not be noticeable. Grades 2 to 4 are called overt hepatic encephalopathy because the symptoms are noticeable.

In the early stages of hepatic encephalopathy, it may be hard to assign a grade. Family members living with someone who is ill may be able to help healthcare professionals by talking about behavior changes that are part of hepatic encephalopathy.

In advanced stages of hepatic encephalopathy, the Glasgow Coma Scale may be used to assess verbal and physical response to sound, touch and other stimuli in people who aren't conscious.

Treatment

Though hepatic encephalopathy may lead to death, it may be treatable if caught early. Knowing why it occurred and treating the cause of hepatic encephalopathy is a key part of treatment. You will need the help of your care team to manage hepatic encephalopathy.

Around 30% to 40% of people with cirrhosis develop hepatic encephalopathy. It must be treated daily to avoid further decline in health.

Treatment usually requires locating the source of infection or bleeding and treating it. If the bout of hepatic encephalopathy is severe, treatment in the intensive care unit, also called ICU, may be needed. In the ICU, your care team will closely monitor you and treat complications that arise, such as pneumonia.

Medications

Several medicines may be used to treat hepatic encephalopathy, including:

• Lactulose. Lactulose lowers the level of ammonia by increasing bowel movements. It also may improve the health of your gut, making recovery easier. Lactulose may be given orally or in an enema.
• Rifaximin (Xifaxan). Rifaximin is an antibiotic that kills bacteria in the gut. In people who have overt hepatic encephalopathy, it may reduce the risk of having more bouts in the future.
• L-ornithine L-aspartate (LOLA). This compound is given to reduce the level of ammonia in the body.
• Polyethylene glycol laxatives. Laxatives that contain polyethylene glycol may be given to empty the bowel quickly. These laxatives also are called PEG laxatives.

Taking a zinc supplement may help convert ammonia into other compounds that can pass out of the body.

Surgery or other procedures

Depending on the grade and severity of the condition, your healthcare team may recommend surgery or other procedures to treat hepatic encephalopathy.

• Bowel enema. If you have constipation or are dehydrated, a bowel enema may be given to restore hydration.
• TIPS surgery. Placement of a transjugular intrahepatic portosystemic shunt, also called TIPS, may improve blood flow, but it also may worsen hepatic encephalopathy in some people. If you have TIPS, you take medicine after surgery to lower the chance that hepatic encephalopathy happens again.

• Liver transplant. A liver transplant is a procedure to replace the liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Liver transplant may reverse hepatic encephalopathy. It may be the best option for people who have had overt hepatic encephalopathy and the only option for people who have end-stage liver disease.

  The best time to have a liver transplant varies. Your care team can order several tests to see if transplantation is an option for you. Depending on where you live, hepatic encephalopathy may not be a condition that allows you to be placed on a waiting list for transplant.

Lifestyle and dietary changes

Changes in diet and eating habits may reduce the risk of future bouts of hepatic encephalopathy.

• Medication changes. Your care team may adjust medicines that you take for other conditions to reduce the risk of falls or other harms.
• Vitamins. If you also lack necessary nutrients, a multivitamin supplement may be given to improve overall health.
• Dietary changes. Eating a healthy diet may help you manage hepatic encephalopathy or conditions that cause it, such as cirrhosis. Ask your care team whether a different diet can help you before making changes.
• Changes in meal timing. Eating small meals during the day may improve mental performance and make it easier to take lactulose. Your care team can help you set up a meal schedule.
• Regular exercise. Becoming fitter may improve your health and ability to sleep well. Your care team may have you start an exercise program to build strength, improve balance or gain endurance. Usually, you will start with short sessions of easy movement and do more as you gain strength.
• Home modifications. Creating a safe living space can reduce your risk of falls and injuries.

Hepatic encephalopathy is a complex condition. Treating hepatic encephalopathy at a less severe grade may not reduce the risk of having a more severe case later. Even if treatment of hepatic encephalopathy is successful, in most cases, you will still have advanced liver disease.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.