One of the many vital jobs performed by the liver is the removal of toxins from the bloodstream. When a diseased liver is not able to perform this task, a variety of problems may develop. A common problem experienced by patients with cirrhosis is hepatic encephalopathy. Simply put, hepatic encephalopathy is confusion associated with underlying liver disease. There are many suspected causes of this type of confusion, but researchers believe the basic problem is the inability of a patient’s liver to clear toxins such as ammonia from the circulation. When ammonia and other toxins accumulate, symptoms including mood (sadness or anxiety) or personality changes (irritability or agitation), poor coordination, drowsiness, memory problems or coma may develop. In more severe cases, patients may become violent or extremely sleepy and difficult to awaken. Triggers of hepatic encephalopathy: A variety of events may cause an episode of hepatic encephalopathy. These include infection, bleeding from the gastrointestinal tract, kidney failure, electrolyte problems from dehyrdration or diuretics (fluid pills), constipation or medications. Many medications may cause or worsen confusion associated with liver disease. These include medications for pain (especially strong pain medications called opiates which include Morphine, Demerol, Dilaudid, and Hydrocodone), medications for anxiety such as Alprazolam (Xanax), antihistamines such as Diphenhydramine (Benadryl) and medications for nausea such as Phenergan. The use of alcohol and illicit drugs may also cause hepatic encephalopathy. Withdrawal syndromes from alcohol as well as some medications such as Alprazolam (Xanax) may be life-threatening. Therefore, it is important to discuss all medication and substance use with your physician. Patients may need medical supervision when stopping benzodiazepines or alcohol. “He’s Not Crazy!” Bill is a very nice gentleman with a caring family. However, one day while he was hospitalized, he abruptly became agitated and took off his clothes. He grabbed scissors nearby and began running around the unit threatening the nurses. I spoke to his wife who reported no history of psychiatric problems and she said, “He’s not crazy!” After he was subdued by security and multiple staff members, he was given Lactulose. Within a period of hours, he was again calm and cooperative. He has since received a liver transplant and is now doing well. Diagnosis of Hepatic Encephalopathy: The more advanced stages of hepatic encephalopathy are easy to diagnose in a patient with known liver disease. Often a patient is very sleepy or may even be in a coma. The earlier stages are more challenging to diagnose and may be confused with depression, anxiety or dementia. Hepatic encephalopathy often results in abrupt and unpredictable changes in a patient’s mood. In contrast, a patient with a mood disorder such as an anxiety or depression often shows chronic (daily) mood symptoms such as worry or sadness, loss of interest, hopelessness, or even suicidal thoughts. Patients with memory problems such as dementia show slow decline in cognitive ability over a period of months or years. Attention and memory problems associated with hepatic encephalopathy often fluctuate from day to day to some degree and improve with treatment of the encephalopathy. During a follow up or hospital visit, a physician will often ask a patient to stretch their arms out and extend their wrists as if attempting to stop traffic. Asterixis is a flapping tremor of the hands which may be seen in hepatic encephalopathy. | A blood ammonia level may be drawn. However, it is important to note that a patient may have hepatic encephalopathy with a normal ammonia level. In other words, the ammonia level may not correlate with the degree of impairment. Ammonia levels are most reliable if analyzed immediately on an arterial blood sample., but many physicians feel ammonia levels are not useful. In cases where the diagnosis is uncertain, other laboratory tests or diagnostic exams such as CT scan, MRI or EEG may also be done to rule out other problems. Treatment of Hepatic Encephalopathy: Hepatic encephalopathy may quickly become a medical emergency. Therefore, it is important to begin treatment of this condition while the cause is being determined. The treatment of confusion due to liver disease involves the administration of Lactulose (Brand names include Kristalose or Enulose). This is a powerful laxative which helps the body clear ammonia through the stool. In early stages, patients may drink this medication, but later stages of hepatic encephalopathy often require the administration of the laxative through a nasogastric tube or enema in the hospital. Antibiotics such as Neomycin and Rifaximin are often used to kill bacteria that produce ammonia in the gastrointestinal tract. Although patients often tolerate Rifaximin better than a laxatives such as Lactulose, there is concern about whether Rifaximin can improve severe hepatic encephalopathy as rapidly as Lactulose. Rifaximin is also significantly more expensive and is not always covered by all insurance companies. Prevention of Hepatic Encephalopathy: Lactulose as a life preserver As a psychiatrist who specializes in the treatment of patients with all types of liver diseases, I educate patients and their families about hepatic encephalopathy on a daily basis. I often hear patients complain about Lactulose. They may complain that the taste is too sweet, doses are forgotten or that it is inconvenient to be near a bathroom. However, I often equate Lactulose to a life preserver as I believe these are some of the most important medications keeping a cirrhotic patient alive. Most patients need to have 2-4 bowel movements daily. Once hepatic encephalopathy emerges, it may rapidly become a life-threatening emergency which requires hospital admission to an intensive care unit and even support by a ventilator. Taking these and other medications as prescribed on a daily basis often prevents this serious event. Lactulose may be more tolerable if taken with a flavored beverage such as fruit juice or milk. It is important to inform your physician about all medications being taken. Almost all medications are processed to some degree by the liver. It is essential to avoid herbal supplements which can cause hepatic encephalopathy or even liver failure. Despite many dramatic claims by supplement companies, there is no known “liver cleanser or purifier” which is safe and effective for the treatment of cirrhosis. I often recommend that patients with cirrhosis wear medic-alert bracelets or pendants. In the event that a patient is found unresponsive or demonstrating unusual behavior, a patient may be taken to the emergency room where prompt treatment for hepatic encephalopathy may be instituted. Often once a patient has a severe episode of hepatic encephalopathy, the physician may recommend that a patient stops driving an automobile or operating dangerous machinery. Hepatic encephalopathy may place a driver at risk for getting lost or injuring or killing others while on the road. Referral for liver transplant evaluation may be appropriate once a patient has an episode of hepatic encephalopathy. |
