HEPATIC ENCEPHALOPATHY: SYMPTOMS, CAUSES, TREATMENT - NEUROPSYCHOLOGY - 2025

The hepatic encephalopathy (HE) is a medical condition characterized by the presence of mental disorders in a person suffering from chronic liver disease. It is considered a neuropsychiatric syndrome characterized by various fluctuating clinical manifestations, from mild symptoms such as tremor or dysarthria, more serious symptoms such as generalized cognitive impairment or vital symptoms such as loss of consciousness and coma.

Hepatic encephalopathy is usually associated with a trigger or severe liver function dysfunction. This type of condition is the product of the accumulation of toxic substances in the bloodstream, due to the loss of liver metabolic function.

There are no specific tests for the diagnosis of hepatic encephalopathy, so the diagnosis is based primarily on clinical suspicion and various complementary techniques.

On the other hand, the therapeutic interventions used in the treatment of hepatic encephalopathy have the objective of eliminating the etiological cause. The most common treatment of choice usually includes disaccharides and nonabsorbable antibiotics.

Characteristics of hepatic encephalopathy

Hepatic encephalopathy (HE) is a brain dysfunction, usually transient, caused by liver failure and manifested as a wide spectrum of psychiatric and / or neurological disorders, ranging from subclinical disorders to coma.

The term encephalopathy is usually used to designate those diffuse neurological pathologies that alter the functionality or brain structure.

Encephalopathies can be caused by a wide variety of etiological 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, head trauma, poor nutrition, or lack of blood flow and oxygen to the brain.

Because of this, generally the term encephalopathy precedes another that describes the cause or reason for the medical condition: hepatic encephalopathy, hypertensive encephalopathy, chronic traumatic encephalopathy, Wernicke encephalopathy, etc.

On the other hand, the term liver is used to designate those conditions that are related to the liver.

Thus, in hepatic encephalopathy, the alteration of neurological functioning is mainly due to the presence of pathologies that affect the efficient functioning of the liver.

Some of the liver diseases are: cirrhosis, hepatitis, liver abscesses, among others.

These conditions mean that the liver is not able to adequately eliminate toxins that are present in the body and the blood, which causes an accumulation of these in the bloodstream, which can lead to significant brain damage.

Frequency

The exact prevalence and incidence of hepatic encephalopathy is not precisely known, mainly due to the scarcity of case studies, the etiological diversity and clinical forms, etc.

Despite this, clinical specialists consider that people affected by cirrhosis may develop hepatic encephalopathy at some point in their life, either with a mild or more severe clinical course.

Specifically, it has been estimated that between 30% and 50% of people diagnosed with cirrhosis have an episode of hepatic encephalopathy.

Signs and symptoms

The clinical course of hepatic encephalopathy is usually transitory, it is generally an acute or short-lived medical condition. However, there are some cases in which hepatic encephalopathy becomes a chronic or long-lasting medical condition.

Furthermore, in long-term cases, hepatic encephalopathy can be permanent or recurrent.

Normally, people with a recurrent course will have episodes of hepatic encephalopathy throughout their lives.

In the case of the permanent form, the symptoms are observed persistently in those people who do not respond favorably to treatment and present permanent neurological sequelae.

The characteristic signs and symptoms of hepatic encephalopathy usually include various types of neurological and psychiatric disorders, ranging from:

• Mild deficits: alteration of sleep-wake patterns, mood swings, memory problems, lethargy and drowsiness.
• Severe deficits: deep coma, cerebral edema, brain stem herniation.

The clinical manifestations of hepatic encephalopathy are characterized by being very heterogeneous and changeable.

Patients affected by hepatic encephalopathy will present symptoms that can be grouped into three areas: altered level of consciousness, neuropsychiatric alteration and neuromuscular alteration.

-Alteration of the level of consciousness

A mildly confused state is usually present, which can progress to a coma. In addition, these conditions are often preceded by states of lethargy or stupor.

• Confusion: it is characterized by a transitory alteration of the mental state with the presence of a slight alteration of the level of attention and vigilance and various cognitive deficits (difficulty to remember, disorientation, difficulty speaking, etc.).
• Clouding or lethargy: it mainly affects attentional level, due to a reduction in the level of vigilance. Usually the patient shows excessive drowsiness, had paused, reduced processing speed.
• Stupor: the level of vigilance is greatly reduced. The affected person presents in a state of sleep and only responds to intense external stimulation.
• Coma: Coma is considered a pathological state or disorder of the level of consciousness. The patient presents in a state of sleep and does not respond to external stimulation.

-Neuropsychiatric disorder

Signs and symptoms that affect the neuropsychiatric area usually include alterations in intellectual capacity, consciousness, personality or language.

In most cases, there is a decrease in processing speed, response, language production, etc. In addition, a significant spatio-temporal disorientation appears

On the other hand, behavioral changes usually begin with the presence of irritability, followed by apathy and alteration of the sleep-wake cycles.

Normally, a partial or total disconnection with the environment is usually observed. In the more severe phases, delusions or psychomotor agitation may appear.

-Neuromusular alteration

On the other hand, the 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: fanning of the toes after stimulation of the sole of the foot.
• Asterixis: reduction or loss of muscle tone in the extensor muscles of the hands.
• Fluttering tremor: trembling in the upper extremities due to the reduction or loss of muscle tone in them.

In addition, in the most serious phases it is possible to observe muscle flaccidity or hyporeflexia (reduction of reflexes), lack of response to intense or painful stimuli and / or presence of stereotyped movements.

Causes

Hepatic encephalopathy (HE) is a type of brain disorder that results in a wide spectrum of neuropsychiatric disorders. In addition, it is a serious or frequent complication caused by liver failure.

The liver is the organ in charge of processing all the toxic waste that is present in the body. These agents or toxins are the product of various proteins, which are metabolized or broken down to be used by other organs.

The presence of a liver disorder in the body causes the liver to be unable to filter all toxins, causing an

accumulation of these in the blood.

Thus, these toxins can travel through the bloodstream to reach the central nervous system (CNS). At this level, these substances alter neuronal function and as a consequence, can cause significant brain injury.

Despite this, the mechanisms of appearance of cognitive alterations are not exactly known, however, different hypotheses have been proposed.

Of all the toxic substances that can accumulate in the bloodstream, experimental studies show that high concentrations of ammonia significantly correlate with the appearance of cognitive deficits.

Specifically, the performance of various laboratory tests has shown that patients suffering from hepatic encephalopathy present high concentrations of ammonia and that the treatment associated with the decrease of this substance leads to a spontaneous improvement of the clinical symptoms.

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:

• Kidney-related pathologies.
• Dehydration
• Infectious processes, such as pneumonia.
• Recent trauma or surgery.
• Consumption of immunosuppressive drugs.

Diagnosis

There is no sufficiently accurate or specific test to establish an unequivocal diagnosis of hepatic encephalopathy.

The diagnosis requires the completion of an accurate clinical history that provides information about the possible causes, symptoms and evolution.

Since many of the symptoms of hepatic encephalopathy are not specific to it, the clinical manifestations are usually observed within the course of other pathologies, therefore, it is essential that the diagnosis is made after ruling out other causes.

In this way, the use of other complementary procedures or tests is also essential:

• General physical examination.
• Liver function test.
• Laboratory tests: blood ammonia levels, potassium levels, creatinine levels, etc.
• Neurological examination: neuropsychological evaluation (cognitive functioning), electroencephalography, neuroimaging tests (magnetic resonance, computed tomography).

Treatment

All existing treatment options for hepatic encephalopathy will depend fundamentally on the etiological cause, the severity of the medical condition and the particular characteristics of the affected person.

Therapeutic intervention, therefore, has the objective of controlling or eliminating the cause and resolving possible secondary medical complications.

In the case of pharmacological interventions, most of the drugs used act by reducing the production and concentration of ammonia. Thus, the most widely used drugs are usually nonabsorbable or antimicrobial disaccharides.

On the other hand, other specialists also recommend the follow-up of non-pharmacological therapeutic approaches, such as the restriction of protein consumption.

Although it is a frequently used measure, it is often used as a short-term treatment for patients who are hospitalized due to moderate or severe hepatic encephalopathy.

Prolonged restriction of protein consumption is harmful for people suffering from hepatic encephalopathy and other types of diseases, since they increase the levels of malnutrition and, in addition, increase the rate of degeneration of muscle mass.

Forecast

Generally, the use of an 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 in concentration, reduced speed of concentration, difficulty in solving problems, etc.

When this occurs, it is essential that an accurate neuropsychological assessment is carried out in order to identify those cognitive areas that perform less 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 a precise and individualized neuropsychological intervention or rehabilitation program.

The fundamental objective of neuropsychological rehabilitation, in this pathology and in others of neuropsychological origin, is fundamentally to achieve a better functionality of those affected areas, as close as possible to the premorbid levels and, in addition, to generate compensatory strategies that allow the patient to adapt effectively to environmental demands.

References

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10. Image source