Hepatic encephalopathy

Treatment of Hepatic Encephalopathy (HE) - Mental Confusion by Ivor Sweigler, PSC News Issue 41 Dec 2008

In the advanced stages of most liver diseases patients may suffer encephalopathy (pronounced ENSEF-ALOP-ATHY—a bit of a mouthful). Encephalopathy is any disorder affecting the brain, especially chronic, degenerative conditions. In its mild form you constantly forget small things: where you put your car keys, your glasses (which can still be on your head!) etc. But in more severe form you can forget your birthday or where you live. This is obviously easily confused with the aging process from your fifties onwards. But in liver disease this is a sign of deterioration. HE nearly always accompanies liver failure. An early indication of HE may be bad breath—but again—that can have a variety of causes. The cause of HE is in the liver‘s inability to clear toxins (which is one of the major functions of the liver), especially ammonia, which is seen as the main culprit. Blood tests for ammonia reveal that 90% of people with HE have elevated blood levels of ammonia. People you live with should be aware that HE can be the cause of irritability, memory loss, apathy, and even change in personality and violence. Other factors which can bring on or exacerbate HE are: some pain medications; excessive consumption of animal protein: too much meat in your diet, which is why a vegetarian diet is often recommended or at least a reduction in meat consumption—which increases ammonia levels; infection: any Helicobacter pylori (H. Pylori) found in the stomach should be eradicated with antibiotics; electrolyte imbalance: such as low potassium; dehydration: which may have been caused by excessive diarrhoea in colitis; kidney dysfunction etc

A number if drugs may be useful in reducing HE but not Lactulose (a laxative) which is still much used for treatment. Dr Debbie Shawcross, Honorary Consultant Hepatologist at King‘s College Hospital, London, who wrote her PHD on this topic, finds no evidence for its efficacy. In a letter to the BMJ in 2004 she writes that systematic randomised trials, of which there have been several, show Lactulose to be ineffective in the treatment of HE “...what should comprise standard medical treatment for hepatic encephalopathy? Lactulose should no longer be included, but strict attention should be paid to treating the precipitating factors, with correction of dehydration, electrolyte and acid base imbalance, constipation, and infection ...the interorgan metabolism of ammonia should be revisited and the recent studies showing the important roles of the small intestine, muscle, and kidneys in regulating the blood concentrations of ammonia considered.”

  • Shawcross, D. Treatment of hepatic encephalopathy. It's not Lactulose. British Medical Journal 2004;329:112 (10 July), doi:10.1136/bmj.329.7457.112

Reviewed 10/05/12

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