Hepatic encephalopathy (HE) is a horrific complication of liver disease, sometimes caused by hepatitis C. HE is a brain disorder that develops when the liver is unable to remove toxins in the body. One toxin is ammonia, produced by the body when proteins are digested. If ammonia builds up in the bloodstream, it can damage the nervous system.
Not only does it affect patients, it can be devastating for those caring for a loved one with HE. It is like watching your loved one become someone else, someone that you don’t know. This pain is captured in the movie, “He’s Back: Wrestling the Monster.”
Roughly seven out of ten people with cirrhosis develop HE, although many cases are mild. Early HE diagnosis is critical, and may help reduce HE progression. People with chronic liver disease are at greater risk of developing a more chronic form of the disorder where symptoms get worse or continue to come back, known as “HE recurrence.”
HE may begin with subtle changes in behavior, mental state, and thinking ability. HE is graded on a scale of zero to four.
- Grade 0 is hard to detect. In this stage, there are memory changes, impaired concentration, slight decrease in intellectual function, or loss of coordination.
- Grade 1 includes a short attention span, sleep problems and mood changes such as depression or irritability.
- Grade 2 is when forgetfulness is noticeable. Energy levels are low; speech may be slurred; doing simple mental tasks such as math or spelling may be difficult. Patients may have tremors, deterioration of handwriting and decreased small motor coordination. They may have shaking of the hands or “flapping” when the arms are held up front of the body with hands lifted like someone making a motion telling someone to “stop.”
- Grade 3 is severe HE. Patients in this stage don’t know where they are, what the day is, or who the president is. They are confused and sleepy. Patients feel anxious and their behavior may be strange.
- Grade 4: The last stage of HE is when the patient is comatose.
Don’t try to diagnose yourself. Most of us have days when we feel like we have grade 2 HE. Low energy and forgetfulness happen to everyone, even those without liver disease. If you have cirrhosis and those around you suspect that you have HE, see your doctor.
Dehydration and electrolyte abnormalities may trigger HE. Other conditions that may lead to HE are metabolic abnormalities, infection, constipation, surgery, eating too much protein, kidney problems and insufficient levels of oxygen in the body.
A variety of medications are used to treat HE, the most common being lactulose. Lactulose is a laxative that absorbs ammonia from the blood and carries it out via the colon. Lactulose is effective in reducing HE symptoms, but it comes with a price: diarrhea, flatulence, bloating, and other gastric problems. Neomycin, rifaximin, metronidazole, zinc, and probiotics are also used to treat HE. Reporting in the June 2014 Clinical Gastroenterology and Hepatology, Manish Kumar Lunia and colleagues found that three months of probiotic administration significantly reduced measurable signs of HE, and was effective in preventing HE in patients with cirrhosis.
Patients with HE should consult with their medical providers before taking all medications. Drugs that suppress the central nervous system, such as sedatives and tranquilizers may worsen the symptoms. Alcohol and recreational drugs may also intensify HE. Drugs containing ammonium, including certain antacids, should be avoided.
Treating the underlying liver condition or liver transplantation may reverse HE or improve the symptoms. Since hepatitis C is a leading cause of end-stage liver disease, it makes sense that if hepatitis C is cured, patients will be spared the misery of HE. For more information about HE, visit the American Liver Foundation’s HE website.
This blog is an excerpt from the author’s August 2014 Healthwise column. To read the entire piece, visit the HCV Advocate.