The hepatic encephalopathy (EH) is a medical condition characterized by the presence of mental disorders in a person suffering from chronic liver disease (Kowdley, 2016).
In addition, it is considered a neuropsychiatric syndrome characterized by diverse fluctuating clinical manifestations, From mild symptoms such as tremor or dysarthria, more severe symptoms such as generalized cognitive deterioration or symptoms of vital importance such as loss of consciousness and coma (Córdoba and Esteban Mur, 2014).
Hepatic encephalopathy is usually associated with a triggering factor or severe dysfunction of liver function (Córdoba And Esteban Mur, 2014).
This type of condition is a product of the accumulation of toxic substances in the circulatory torrent, due to the loss of function
Hepatic metabolism (Cortés and Córdoba, 2010).
For the diagnosis of hepatic encephalopathy there is no specific evidence, so the diagnosis is based
Fundamentally in clinical suspicion and in various complementary techniques (Kowdley, 2016).
On the other hand, the therapeutic interventions used in the treatment of hepatic encephalopathy are aimed at eliminating the etiological cause (Kowdley, 2016).
The most common treatment of choice usually includes disaccharides and nonabsorbable antibiotics (Kowdley, 2016).
Characteristics of hepatic encephalopathy
Hepatic encephalopathy (HD) is a transient cerebral dysfunction caused by liver failure and manifests itself as a broad spectrum of psychiatric and / or neurological disorders, ranging from subclinical disorders to coma (The American Association for the Study Of Liver Diseases, 2014).
The term encephalopathy is often used to denote diffuse neurological pathologies that alter brain function or structure (National Institute of Neurological Disorders and Stroke, 2010).
Encephalopathy can be caused by a wide variety of etiologic causes: infectious agents (bacteria, Viruses, etc.), metabolic or mitochondrial dysfunction, increased intracranial pressure, prolonged exposure to toxic elements (chemicals, heavy metals, radiation, etc.) Brain tumors , Traumatic brain injury , Poor nutrition, or lack of blood flow and oxygen in the brain
(National Institute of Neurological Disorders and Stroke, 2010).
Because of this, the term encephalopathy generally precedes another that describes the cause or reason of the medical condition: encephalopathy Hepatic, hypertensive encephalopathy, chronic traumatic encephalopathy, Wernicke's encephalopathy, etc. (Encephalopathy, 2016).
On the other hand, the term hepatic, is used to designate those conditions that are related to the liver.
Thus, in hepatic encephalopathy, the alteration of neurological functioning is fundamentally due to the presence of pathologies that affect the efficient functioning of the liver.
Some of the liver diseases are: cirrhosis , hepatitis , Hepatic abscesses , Among others (National Institutes of Health, 2016).
These conditions make the liver unable to adequately remove toxins that are present in the body and blood, so Produces an accumulation of these in the bloodstream, leading to significant brain damage (Kivi, 2012).
Frequency
The prevalence and exact incidence of hepatic encephalopathy is not precisely known, mainly due to the Scarcity of case studies, etiological diversity and clinical forms, etc. (Cortés and Córdoba, 2010).
Despite this, clinicians consider that, people affected by cirrhosis may develop hepatic encephalopathy at some point in their life, whether with a clinical course Milder or more serious (Cortés and Córdoba, 2010).
Specifically, it has been estimated that between 30% and 50% of people diagnosed with cirrhosis have an episode of encephalopathy Hepatic a (Cortés and Córdoba, 2010).
Signs and symptoms
The clinical course of hepatic encephalopathy is usually transient, generally an acute or short-lived medical condition. However, there are some cases in which hepatic encephalopathy Chronic or long-term medical pathology (Kivi, 2012).
In addition, in long-term cases, hepatic encephalopathy may be permanent or recurrent.
Typically, people who have a recurrent course will have episodes of hepatic encephalopathy throughout their lives (Kivi, 2012).
In the case of the permanent form, symptoms are persistently observed in those who do not respond favorably To treatment and have permanent neurological sequelae (Kivi, 2012).
Signs and symptoms characteristic of hepatic encephalopathy often include various types of neurological and psychiatric disorders, ranging from (Kowdley, 2016):
- Mild deficits : Altered sleep-wake patterns, mood swings, memory problems, lethargy, and dizziness.
- Severe deficits : Deep coma, Cerebral edema , Herniation of brainstem .
The clinical manifestations of hepatic encephalopathy are characterized by being very heterogeneous and changing (Cortés and Córdoba, 2010.
Patients affected by hepatic encephalopathy will present a symptomatology that can be grouped into three areas: altered level of consciousness, neuropsychiatric alteration and neuromuscular alteration (Cortés and Córdoba, 2010).
Alteration of the level of consciousness
Usually there is a mild state of confusion that may progress to a coma. In addition, these conditions are usually preceded by States of lethargy or stupor (Cortés and Córdoba, 2010).
- Confusion : It is characterized by a transient alteration of the mental state with presence of slight alteration of the level of attention and Surveillance and various cognitive deficits (difficult to remember, disorientation, difficulty speaking, etc.).
- Obnubilation or lethargy : It affects fundamentally at the attentional level, due to a reduction of the level of surveillance. Normally the Patient shows excessive drowsiness, bean paused, reduced processing speed.
- Stupor : The level of surveillance is considerably reduced. The affected person presents in a state of sleep and only responds to the Intense external stimulation.
- Coma : The coma is considered a pathological state or disorder of the level of consciousness. The patient presents in a state of sleep and does not Responds to external stimulation.
Neuropsychiatric alteration (Cortés and Córdoba, 2010)
The signs and symptoms that affect the neuropsychiatric area usually include alterations of the intellectual capacity, conscience, personality or language.
In most cases, there is a decrease in processing speed, response, language production, etc. In addition, a Significant spatial-temporal disorientation
On the other hand, behavioral changes usually begin with the presence of irritability, followed by apathy and altered sleep cycles and vigil.
Usually, a partial or total disconnection with the environment is usually observed. In the most severe phases, delusions or agitation may occur Psychomotor.
Neuromuscular disorder (Cortés and Córdoba, 2010)
On the other hand, signs and symptoms related to the neuromuscular area usually include: hyperreflexia, appearance of Babinskiy signs, asterixis or fluttering tremor.
- Hyperreflexia : Presence of exaggerated or disproportionate reflexes.
- Babinski's Sign : Opening of the toes in fan after the stimulation of the sole of the foot.
- Asterixis : Reduction or loss of muscle tone in the extensor muscles of the hands.
- Fluttering tremor : Tremor in the upper extremities due to the reduction or loss of muscle tone in them.
In addition, in the more severe phases it is possible to observe muscle flaccidity or hyporeflexia (reduction of Reflexes), absence of response to intense or painful stimuli and / or presence of stereotyped movements.
Causes
Hepatic encephalopathy (HE) is a type of encephalic disorder that results in a wide spectrum of abnormalities Neuropsychiatric disorders. In addition, it is a serious complication or frequent product of liver failure (Córdoba and Esteban Mur, 2014).
The liver is the organ in charge of processing all the toxic residues that are present in the organism. These agents or toxins are the product of Various proteins, which are metabolized or decomposed for use by other organs (Kivi, 2012).
The presence of a hepatic alteration in the organism, causes the liver to be unable to filter all the toxins, causing a
Accumulation of these in the blood (Kivi, 2012).
Thus, these toxins can travel through the bloodstream to reach the central nervous system (CNS).
At this level, these substances alter the neuronal function and as a consequence, they can cause important injuries at the cerebral level (Córdoba and Esteban Mur, 2014).
In spite of this, the mechanisms of the appearance of cognitive alterations are not exactly known, however, different hypotheses have been proposed (Kowdley, 2016).
Of all toxic substances that can accumulate in the bloodstream, experimental studies show that high concentrations of ammonia correlate significantly with the occurrence of cognitive deficits (Kowdley, 2010).
Specifically, the performance of various laboratory tests has shown that patients with hepatic encephalopathy present High concentrations of ammonia and that, in addition, the treatment associated with the reduction of this substance results in a spontaneous improvement of the Clinical symptomatology (Kowdley, 2010).
However, ammonia is not the only medical condition that can lead to the development of hepatic encephalopathy.
In this way, several conditions have been identified that can trigger the development of hepatic encephalopathy (Kivi, 2012):
- Pathologies related to the kidney.
- Dehydration.
- Infectious processes, such as pneumonia.
- Trauma or recent surgery.
- Consumption of immunosuppressive drugs.
Diagnosis
There is no sufficiently precise or specific test to establish an unequivocal diagnosis of hepatic encephalopathy (Córdoba et al. 2014).
The diagnosis requires the accomplishment of a precise clinical history that, provides information about the possible causes, Symptoms and evolution (Cortés and Córdoba, 2010).
Because many of the symptoms of hepatic encephalopathy are not specific to it, clinical manifestations are usually observed within course Of other pathologies, therefore, it is fundamental that the diagnosis is made after ruling out other causes (Cortés and Córdoba, 2010).
In this way, the use of other complementary procedures or tests is also essential (National Institutes of Health, 2015):
- General physical examination .
- Examination of liver function .
- Lab tests Levels of ammonia in blood, levels of potassium, levels of Creatinine , etc.
- Neurological examination : Neuropsychological assessment (cognitive functioning), Electroencephalography , Neuroimaging tests ( resonance Magnetic, Computed tomography ).
Treatment
Every options Of existing treatment for hepatic encephalopathy will depend fundamentally on the etiological cause, the severity of the medical condition and the particular characteristics of the person affected (Khan, 2016).
The therapeutic intervention, therefore, has the objective of controlling or eliminating the cause and resolving The possible secondary medical complications (Khan, 2016).
In the case of pharmacological interventions, most of the drugs used affect the production and concentration of ammonia. Thus, the most commonly used drugs are non-absorbable or antimicrobial disaccharides (Cortés and Córdoba, 2010).
On the other hand, other specialists also recommend the follow-up of non-pharmacological therapeutic approaches, such as the restriction of protein consumption (Khan, 2016).
Although it is a commonly used measure, it is often used as a short-term treatment for patients
Who are hospitalized due to moderate or severe hepatic encephalopathy (Cortés and Córdoba, 2010).
Restricting protein consumption on a long-term basis is harmful for people with hepatic encephalopathy and other types
Diseases, since they increase the Levels of malnutrition And also increase the rate of degeneration of muscle mass (Cortés and Córdoba, 2010).
Forecast
Generally, the use of adequate medical treatment on the etiological cause of hepatic encephalopathy implies a favorable recovery of the Affected person.
However, in many cases after recovery significant neurological sequelae begin to develop.
Therefore, it is possible that those affected present attentional alterations, memory problems, Difficulty concentrating , Reduction of Speed of concentration, difficult to solve problems, etc.
When this occurs, it is essential that a precise neuropsychological assessment is performed in order to identify those cognitive areas that present A performance lower than expected for their age group and educational level.
Once the altered functions have been identified, the professionals in charge of the case will design an intervention or rehabilitation program Accurate and individualized neuropsychology.
The fundamental objective of neuropsychological rehabilitation, in this pathology and in others of neuropsychological origin, is fundamentally to achieve a Better functioning of those affected areas, as close as possible to premorbid levels and, in addition, generate compensatory strategies that Allow the patient to adapt effectively to the environmental demands.
References
- AASLD. (2014). Hepatic Encephalopathy in Chronic Liver Disease. Retrieved from The American Association for the Study of Liver Diseases.
- Córdoba, J., & Mur, E. (2010). Hepatic encephalopathy. Gastroenterol Hepatol, 74-80.
- Cortés, L., & Córdoba, J. (2010). 63. Epileptic Encephalopathy. Obtained from Spanish Association of Gastroenterology.
- Encefalopatia.net. (2016). Hepatic encephalopathy. Obtained from Encefalopatia.net.
- Kahn, A. (2016). What Is Hepatic Encephalopathy? Retrieved from Healthline.
- Kivi, R. (2016). Encephalopathy. Retrieved from Healthline.
- NIH. (2010). Encephalopathy. Retrieved from the National Institute of Neurological Disorders and Stroke.
- NIH. (2015). Hepatic encephalopathy. Obtained from MedlinePlus.
- Shaker, M. (2014). Hepatic Encephalopathy. Obtained from Cleveland Clinic.
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