# Hepatic Encephalopathy --- **Hepatic encephalopathy** or **HE** is a quite complex and dangerous condition of a swelling of the [[brain]] due to an injury to the [[liver]]. Broadly speaking HE is caused by a build up of toxins such as the metabolic waste-product [[ammonia]], which under normal conditions is broken down and cleared by the liver. This can cause confusion, altered mental status, and really disrupts the ![[hepatic encephalopathy.png]] Ammonia is made from the breakdown of proteins, but the major contributor are the intestinal bacteria. ## Triggers HE can be set off in people with liver conditions by certain triggers: - [[GI bleed]] - infection - certain medications - not eating enough - [[constipation]] - causes a build up of ammonia ## Signs & Symptoms The signs and symptoms of hepatic encephalopathy mirror other neurological problems. One specific sign is a condition called **asterixis**, which is an involuntary tremor of the hands in a specific way when arms are extended and hands are in dorsiflexion. Other s/s are: - altered mental status - constructional apraxia - sleep disturbances - they're up all night and sleep all day - this is usually one of the first signs. - seizures - coma - fetor hepaticus - a sweet, fecal smelling breath | stage | signs & symptoms | EEG changes | | :--: | ---- | ---- | | 1 | - normal levels of consciousness<br>- periods of lethargy and euphoria<br>- reversal of nigh/day sleep patterns<br>- impaired writing/ability to draw line figures | normal EEG | | 2 | - increased drowsiness<br>- disorientation. agitation<br>- mood swings, inappropriate behavior<br>- asterixis<br>- fetor hepaticus | abnormal EEG with generalized slowing | | 3 | - stuporous, difficult to rouse, sleeping most of the time<br>- marked confusion, incoherent speech<br>- asterixis<br>- increased deep tendon reflexes<br>- rigidity of extremities | markedly abnormal EEG | | 4 | - comatose<br>- may not respond to painful stimuli<br>- absence of asterixis<br>- absence of deep tendon reflexes<br>- flaccidity of extremities | markedly abnormal EEG | ## Diagnostic Tests You can't test for HE directly, but ammonia blood levels are a good way of checking for HE. Ammonia greater than 200mcg/dL is associated with [[intercranial pressure#Complications of Increased ICP|brain herniation]]. ## Treatment Treatment for hepatic encephalopathy consists of lowering serum ammonia levels and treating the liver condition. - treatment will almost certainly include **lactulose**, which acidifies the colon an reduces the absorption of ammonia. - it's an [[laxatives|osmotic laxative]] - can cause a gas buildup, which can make it hard for surgeons if they're going to do a [[organ transplant|liver transplant]] - the goal is 2-3 soft stools a day - sometime they give antibiotics to reduce [[ammonia]]-producing gut bacteria - usually neomycin and rifaximin ___