Hepatic encephalopathy (HE) is a liver condition caused by the buildup of ammonia and other toxins in the brain when the liver is unable to remove them from the blood. This buildup can cause a range of symptoms — from confusion, forgetfulness, and personality changes to a loss of brain function. HE is a common complication of cirrhosis of the liver.
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What Is Hepatic Encephalopathy?
Hepatic encephalopathy (HE) is a liver condition caused by the buildup of ammonia and other toxins in the brain when the liver is unable to remove them from the blood.
The liver’s primary function is to act as a filter in removing toxins from your blood. When you have liver disease, the liver may not be able to do its job, allowing toxins to run through your bloodstream and reach your brain. When these toxins eventually build up in the brain, they can cause HE symptoms ranging from confusion, forgetfulness, and personality changes to a loss of brain function.
HE is a common complication of cirrhosis of the liver. More than 7 out of 10 people with cirrhosis develop some form of HE. The exact number is unknown because the symptoms can be subtle in the early stages of the disease.
What are the types of hepatic encephalopathy?
There are two types of HE.
- Acute HE comes on fast and may be a sign of liver failure.
- Chronic HE takes longer to develop. Sometimes people recover only to have it recur later.
Doctors classify the severity of HE by stages.
- Stage 0 — Minimal HE: Slight changes in memory and concentration.
- Stage 1 — Mild HE: Mood changes and sleep problems.
- Stage 2 — Moderate HE: Inappropriate behavior, slurred speech, trouble doing basic math.
- Stage 3 — Severe HE: Disorientation, extreme sleepiness, or anxiety.
- Stage 4 — Coma: Unconsciousness and unresponsiveness.
What causes hepatic encephalopathy?
Hepatic encephalopathy is caused by the buildup of toxins in the brain. HE is a common complication of cirrhosis of the liver, liver disease, and liver failure.
Hepatic encephalopathy risk factors
You’re more likely to get HE if you:
- Have cirrhosis or another severe liver disease.
- Have had a previous episode of HE.
- Have portal hypertension.
- Have undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure.
If you've had HE once, these things can trigger another bout of it:
- Alcohol use disorder.
- Azotemia – Abnormally high levels of nitrogen-containing compounds, such as creatinine and urea.
- Bleeding from the digestive tract.
- Constipation.
- Dehydration.
- Eating too much protein.
- Electrolyte imbalances.
- Infections.
- Kidney dysfunction or kidney failure.
- Lack of potassium.
- Low oxygen levels.
- Low levels of salt in the blood.
- Surgery.
- Taking drugs that act on the central nervous system, including antidepressants, benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs), sleeping pills, opioids, and more.
Complications of hepatic encephalopathy
If left untreated, HE will get worse. It will not get better on its own.
Complications from HE may range be subtle, such as mild forgetfulness, to severe, including extreme confusion or disorientation, personality changes, lethargy, and coma.
How can I prevent hepatic encephalopathy?
The only sure way to prevent HE is to keep your liver healthy. People who drink too much alcohol or have hepatitis are at risk for liver disease.
If you have liver disease, you can prevent further damage by:
- Eating a healthy diet.
- Maintaining a healthy weight.
- Not drinking alcohol.
- Seeing your doctor on a regular basis.
How common is hepatic encephalopathy?
HE is considered common among people with liver disease. Population-based studies have shown that 44% to 51% of people with cirrhosis of the liver will have at least moderate HE symptoms, and that up to 80% of those with cirrhosis will have at least mild symptoms of HE.
What Are the Signs and Symptoms of Hepatic Encephalopathy?
Mild to moderate HE symptoms include:
- Forgetfulness and confusion.
- Inability to concentrate.
- Inappropriate behavior.
- Moodiness, irritability, or other personality changes.
- Musty, sweet breath.
- Slurred speech.
- Sleeping during the day.
- Trouble doing basic math or writing.
Severe symptoms of HE include:
- Anxiety or fearfulness.
- Depression.
- Disorientation.
- Extreme sleepiness.
- Inability to do basic mental tasks.
- Jumbled speech.
- More pronounced confusion.
- Sluggish movement.
- Shaking of arms or hands (“flapping”).
When should I see a doctor about my hepatic encephalopathy symptoms?
If you have liver disease, you should see your doctor at the first sign of HE. The sooner you get treatment, the more likely you are to recover.
How Do You Diagnose Hepatic Encephalopathy?
There is no diagnostic test for HE. Instead, HE is a diagnosis of exclusion, meaning that doctors will rule out other possible problems first.
Your doctor will do a physical exam and talk to you about your health history.
Your doctor may order these tests:
How Do You Treat Hepatic Encephalopathy?
UPMC offers specialized hepatic encephalopathy treatment. For best results, get a diagnosis and treatment as early as possible.
Treatment involves:
Medicine to treat HE
One goal of treatment is to reduce the amount of ammonia in your blood. Doctors treat HE with antibiotics and lactulose to reduce the levels of ammonia and other toxins in the blood.
- Antibiotics stop the growth of some bacteria that create toxins.
- Lactulose draws ammonia into your colon, where it will pass out of your body in stool (poop).
Lifestyle changes to treat HE
If you have HE, you should avoid drinking alcohol.
A dietitian may also suggest nutritional changes. Eating too much protein produces an excess amount of ammonia in the blood. You may need to avoid eating meat and eggs.
Liver transplant to treat HE
In severe cases of HE, you may need a liver transplant.
Why Choose UPMC for Hepatic Encephalopathy Care?
- Our doctors are experts at treating complications from liver disease, including HE.
- UPMC is also home to one of the most experienced liver transplant centers in the country.
- We offer cutting-edge treatments and therapies for those with cirrhosis and other liver diseases.
