Hepatic encephalopathy: symptoms, treatment,diagnostics

Update: October 2018 Hepatic encephalopathy is a condition
accompanied by a malfunction of the brain,
which occurred due to impaired liver function. If a
the liver “turns off” abruptly, that is, it suffers immediately in a short time
a large amount of its tissue, acute hepatic
encephalopathy – a condition characterized by increasing
sleepiness, which in most cases ends in death.
When liver tissue gradually loses its cells, the work
The brain also does not immediately deteriorate. Initially, personal and
intellectual functions, and only after a long period of time
a person becomes drowsy and falls into a coma.

Hepatic encephalopathy is a condition that requires medical treatment.
help. With остром нарушении работы мозга проводится
drug correction. She is направлена на частичное замещение
the main functions of the liver (fully take over the work of the hepatic
tissue medicine is not able to) until its tissue is restored.
Chronic hepatic encephalopathy has a better chance of
cure: in most cases, a liver lobe transplant can
completely save the situation, returning the person’s health and personality.

Folk treatment can only be used for chronic
hepatic encephalopathy, but only on the recommendation of a doctor and only
as an adjunct to primary therapy.

What can cause hepatic encephalopathy

Hepatic encephalopathy is a condition that is indicative of
damage to liver tissue. This can happen when:

  • acute hepatitis caused by hepatitis viruses (especially
    hepatitis B virus or a combination of viruses B and D, hepatitis E virus
    – in pregnant women, less often – with hepatitis C and A viruses);
  • acute liver damage caused by other viruses: a simple
    herpes, yellow fever, rarely – cytomegalovirus, Epstein-Barr
    virus, varicella virus (varicella-zoster virus);
  • damage to the liver by rickettsia, mycoplasmas, several
    mushrooms;
  • liver abscess;
  • purulent inflammation of the intrahepatic bile ducts
    (cholangitis);
  • poisoning with some mushrooms: heliotrope, pale toadstool,
    cross;
  • poisoning by poisons that specifically affect the liver
    cells: ethyl alcohol, phosphorus, chlorocarbons;
  • overdose of certain drugs: paracetamol, aminazine,
    tetracycline, ketoconazole, anti-TB antibiotics,
    male sex hormones, sulfonamides;
  • several repetitions made at short intervals of time
    ftorotanovyh anesthesia (now not carried out);
  • Reye’s syndrome – brain and liver damage caused by taking
    acetylsalicylic acid (less commonly – other antipyretics)
    children during ARVI, influenza, enterovirus and other viral
    infections;
  • Sheehan syndrome – acute liver damage that occurs in
    pregnant for an unknown reason;
  • Wilson’s disease – a violation of the exchange of copper with the deposition
    in the liver;
  • thrombosis, compression of the tumor or transection during surgery
    large vessels that feed the liver;
  • multiple liver metastases;
  • severe course of blood cancer: hemoblastosis,
    Hodgkin’s disease;
  • lesion of the liver drugs for chemotherapy.

Chronic hepatic encephalopathy develops over several
other reasons. It:

  • alcoholic liver disease;
  • gallstone disease with bile stasis in the biliary tract;
  • autoimmune hepatitis;
  • chronic viral hepatitis;
  • encephalopathy with cirrhosis;
  • liver damage by worms;
  • hepatic tissue tumors;
  • liver tuberculosis;
  • chronic heart failure that is worsened
    venous outflow from the liver tissue;
  • galactosemia;
  • glycogenosis;
  • operations to create an artificial path for blood between
    the system of the portal vein of the liver and the hollow veins;
  • long-term use of certain drugs.

Depending on the cause, hepatic encephalopathy develops
one of three mechanisms:

  1. hepatocellular: liver tissue and products are destroyed
    its destruction enters the bloodstream;
  2. porocaval: toxic products formed by intestinal
    microflora, are absorbed in the intestines, but not neutralized in
    liver, and go to the general bloodstream and in the brain. Characteristic of cirrhosis
    the liver;
  3. mixed: there is also a destruction of the liver tissue, and
    the entry of protein rotting products into the blood and, with it, into the brain
    the cloth. Characteristic of cirrhosis печени.

Hepatic encephalopathy develops when suffering
large amount of liver tissue.

The first (hepatocellular) mechanism can cause and
acute and chronic encephalopathy, while porcavale and
mixed mechanisms usually develop with chronic
encephalopathy.

What is the basis of hepatic encephalopathy

To say exactly why hepatic encephalopathy develops,
scientists still can not. There are three theories explaining
why when the liver tissue dies off, brain activity is disturbed, and
each of them has strong evidence:

  1. Toxic (ammonia) theory. She is говорит о том, что работа
    brain deteriorates due to toxins (primarily ammonia and
    products protein decay), which are formed to a greater extent in fat
    intestine, as well as in the muscles, in the small intestine and in the liver – with
    splitting proteins in it. The body is always trying to maintain
    the balance between ammonia formation and neutralization, but if that
    не происходит, токсины поступают по воротной вене в liver. There
    ammonia would have to be included in the reaction cycle called
    �“Ornithine cycle” to make urea. But since
    liver cells are damaged, then the rate of neutralization of toxins and
    ammonia is severely slowed.  They, along with those substances
    that have passed the liver and hit immediately into the inferior vena cava, and
    are toxic to the brain. Improve the situation can
    �”Correct” amino acids that neutralize ammonia “in
    bypassing the ornithine cycle – and along the path of formation from it
    glutamine. These are arginine, glutamic acid, ornithine and aspartate.
    is heи превращают аммиак в нетоксичный для мозга glutamine.
  2. Theory of false neurotransmitters. She is говорит о том, что при
    liver failure increases protein rot in fat
    intestines. The body is trying to use some amino acids –
    those that have a branched chain structure (leucine, valine,
    isoleucine) – as energy. As a result, the blood flow
    aromatic amino acids (phenylalanine, tyrosine, tryptophan),
    which normally should be metabolized in the liver. They reach
    to the brain and stimulate the formation of transmitting substances that are there
    should not be (false neurotransmitters). It slows down the system.
    enzymes that must convert tyrosine to dioxyphenylalanine
    (it produces dopamine and norepinephrine). Also in the brain
    Phenylethylamine, Octopannin, which inhibit its work accumulate,
    tyronin. This dictates the need to stop the receipt
    protein nutrition, replacing it with the introduction of only balanced
    mixtures consisting of the correct amino acids.
  3. The hypothesis of neuroglia (the so-called tissue, which is in the head
    auxiliary brain). She is говорит о том, что появляющиеся при
    liver failure toxins as well as imbalance
    amino acids, lead to edema of the neuroglia and its violation
    functioning. But if with cirrhosis or liver fibrosis toxic
    for brain compounds are formed in the intestines, then in acute
    hepatitis caused by various viruses, they are products
    destruction of the liver.

Symptoms

The term “encephalopathy” in medicine means disruption of work
brain (“encephalon” – the brain, “paty” –
disease). It may occur as a result of various
non-inflammatory causes: circulatory disorders of the brain (for example,
with the defeat of the vessels that feed it, atherosclerotic or
diabetic process), changes in its metabolic processes,
damage in case of injury.

Symptoms энцефалопатии во всех этих случаях будут очень похожи.
Therefore, with a gradual deterioration of the brain, to say without
surveys why a person suddenly began to talk, forget
words and events, lose orientation, no doctor can.

Another thing – acute hepatic encephalopathy. She is развивается
according to special rules, so it has its own characteristics.

Acute hepatic encephalopathy

Hepatic encephalopathy stages

Her symptoms appear in a strictly defined order, as
allows to distinguish 4 stages of hepatic encephalopathy:

Stage 1 is called precoma I

This is a condition that should force the relatives of the patient.
urgently call an ambulance. Its development may indicate
hiccups due to jaundice, vomiting or bleeding
gum.

Prekoma I is manifested by a change in mood: the appearance
uncharacteristic depression, anxiety or, conversely, very good
moods. A person can search for non-existent things, express
crazy ideas, but answering questions almost adequately,
surrounding learns.

A person becomes a sleepy day, and at night insomnia torments. is he
a little overshots when performing a finger-nose test; brushes
hands while doing a little shiver. If a на этой стадии выполнить
EEG (electroencephalogram), you can see violations from
alpha rhythm: its irregularity, an increase in the amplitude of the waves.

This condition can appear as 1 week jaundice, and
during the first 24 weeks from the onset of viral or toxic
hepatitis A. Further development of symptoms may occur as in
for 1-3 days or even several hours (this is called
fulminant hepatitis and has a poor prognosis) and
stretch for a few weeks. The slower stage replaces
the other, the greater the chance of survival.

Stage 2 – Precoma II

A person is conscious, you can communicate with him, but his speech is blurred, and
he himself is slowed down (less often – excited, foolish or angry),
disoriented. Visually and acoustically observed
hallucinations that leads a person into a motor state
excitement. The patient answers questions, but does not always fall asleep.
With выполнении пальце-носовой пробы руки не просто дрожат, а пальцы
all the time trying to touch the palms (as if they clap,
so this symptom called clapping tremor or
astratrixis). There is also a violation of the account, loss of feeling.
time amnesia.

On EEG – sharply slowed down alpha rhythm, the appearance of theta and
delta waves.

Stage 3 – coma I

At this stage, the person is already unconscious, it is impossible to call him.
His pupils are dilated, sluggish to light. Various tendon
reflexes can be called. In response to a painful stimulus (for example, with
rubbing the earlobe) a grimace appears on the face, but the eyes do not
are opening up. From the body comes the smell of raw liver.

There are no alpha and beta waves on the EEG, only three-phase
delta waves.

Stage 4 – coma II

Consciousness is not. Tactile, voice and even pain stimulation is not
cause neither eye opening, nor any grimace, nor even
changes in pulse or breathing, indicating that the person
hears the one who calls. Pupils do not respond to light. If a на этой стадии
the patient is still breathing not with the help of an artificial ventilation apparatus,
it is noticeable that his breathing is deep and uneven, at any moment
may stop.

Heart rhythm abnormalities, uterine or
gastrointestinal bleeding. The temperature may rise.
After some time, the kidneys are disrupted: they stop
excrete urine (a symptom called anuria). With anuria, man lives
from several hours to several days, then dies. With
Stage II coma return is almost impossible.

On EEG – synchronous delta waves, there is a tendency to
isolines.

Chronic hepatic encephalopathy

Symptoms печеночной энцефалопатии хронического характера заметно
are different. is heи также протекают в несколько стадий:
compensated, subcompensated and decompensated.
The fourth stage – hepatic coma, which is not different from the stage
coma II in the acute process.

The compensated stage appears when the patient can still not
to know that his hepatitis has passed into the chronic stage, or that
he has cirrhosis of the liver. Her appearance can be suspected by such
symptoms like:

  • morning sickness;
  • loss of appetite up to aversion to food (usually to
    oily), but there may be a perversion of taste;
  • faster fatigue;
  • behavior change, the emergence of new personality traits.

These signs are so non-specific that when you go to a doctor
the latter can prescribe different examinations for a long time before
will find the cause.

Subcompensated stage can be suspected by yellowing of the skin,
redness of the palms and feet, the appearance of spider veins,
increased weakness. The man seems to be getting fat in the abdomen: this
fluid accumulates in the abdominal cavity (ascites).

His personality change progresses: he usually becomes
demanding, irritable; reduced sexual desire
memory deteriorates.

Endocrine disorders are noted: an increase in the mammary glands in
men or their reduction – in women, testicular atrophy in men.

With декомпенсированной стадии диагноз поставить легко. Skin
integuments are apparently pale yellow, swollen. Big belly due
ascites, and limbs, on the contrary, thin. Man becomes drowsy
periodically it is difficult to obtain. Periods appear
агрессивности, двигательного excitement.

The decompensation stage ends with the appearance of a coma. On her background
there is a diverging strabismus, convulsions.

Diagnostics

You can make a diagnosis according to the following studies:

  • liver tests: the level of bilirubin, ALT, increases in less
    degree – AST;
  • coagulogram: reduced prothrombin index and INR;
  • urinalysis: increased levels of bilirubin and urobilin;
  • Ultrasound of the liver: in case of acute liver failure, liver
    decreases, while chronic, on the contrary, becomes large;
  • liver biopsy: performed in chronic encephalopathy with
    To clarify the diagnosis (ultrasound and even MRI can not accurately show
    the nature of changes in the liver tissue, especially in primary
    stages)

Hepatic Encephalopathy Therapy

Treatment of hepatic encephalopathy – acute or chronic –
should start as early as possible. Acute encephalopathy is treated
only in the hospital, in the intensive care unit, the initial
chronic stage can be treated at home.

The first step in treatment is diet. Protein proteins are excluded from the diet.
products (meat, eggs, fish, cottage cheese, legumes). But amino acids
the body is still needed, but certain ones are needed – not aromatic,
and branched chain. This is leucine, valine, isoleucine. is heи
are contained in special mixtures for enteral nutrition: Nutriene
Gepa, Gepamine. Patients in consciousness use them independently, in
the amount calculated by the doctor. Patients in the state of precoma II or
comas of any level are introduced into the probe.

All fresh and pickled vegetables, berries and
fruit, any broth, mushrooms, cabbage, milk, fatty dairy
products, sweets, alcohol, coffee. Patients with acute hepatic
enfephalopathy food is carried out only using the above
mixes.

Constantly refined electrolyte balance: blood test is taken
for potassium and sodium. With повышении уровня
First, in order to avoid cardiac arrest, everything is removed from the diet.
potassium-containing foods (bananas, baked potatoes, dried fruits).
If there is a lot of sodium, then salt is completely excluded, and all nutritious
mixtures are prepared in distilled water (there is neither potassium nor
sodium).

Be sure to hold infusion support (droppers).
Intravenously administered or polyionic solutions (“Yonosteril”, “Solution
Ringer’s “) plus glucose-potassium-insulin mixtures with elevated
glucose content – if there is no violation by sodium and potassium,
or only solutions of amino acids (“Gepasol A”, “Aminoplazmal”,
�”Infesol”) and fat (“Lipofundin”) – if the levels of potassium and sodium
are at critical elevations. When the level of potassium is above 6 mmol / l
the patient is transported to the artificial kidney department.

Plasma transfusion is also carried out: it contains substances
necessary for blood clotting.

Treatment of acute hepatic encephalopathy and decompensated
chronic liver failure necessarily includes
introduction:

  • Lactulose preparations (“Lactulose”, “Normase”, “Duphalac”). She is
    need to suppress the reproduction of pathological intestinal flora and
    reduce ammonia production. The dose of lactulose can be from 20 ml
    three times a day to 50 ml twice a day.
  • Antibiotics that are given by mouth and will act
    only in the intestines, inhibiting the growth of pathogenic intestinal flora there,
    producing ammonia. These are “Rifamixin”, “Norfloxacin”,
    �”Kanamycin.” Intravenous antibiotics are undesirable (unless
    the reason is not liver abscess or purulent cholangitis), since they
    additionally increase the load on the damaged liver. Doses
    antibiotics are recalculated daily based on work
    the kidneys.
  • Drugs that will convert ammonia to non-toxic
    glutamine. This is “Hepa-Mertz” and its domestic analogue “Ornitoks” in
    maximum dosage. In the absence of funds for this drug
    You can use ampullable drug “Glutargin” 40%, administered
    intravenous drip.
  • Sorbents: Polysorb, White Coal, Enterosgel, Filtrum
    STI “. They are also administered in the maximum possible dosage.
  • Drugs that inhibit the production of hydrochloric acid in
    the stomach. These are intravenous drugs “Kontralok”, “Omez”. With
    chronic encephalopathy “Rabeprazole” 40 mg or “Omeprazole” in the dose
    40 mg / day can be taken by mouth.
  • Preparations blocking proteolysis. This “Contrykal” and “Gordoks.”
    They are needed for the prevention and treatment of bleeding.

With уровне сознания ниже прекомы I капельное введение растворов
Type 5% glucose or Ringer’s solution is prohibited: they have a low
osmolarity, as a result, increase the swelling of the brain, worsening
forecast.

For any encephalopathy, high enemas are required.
performed daily with cool water in which is dissolved
soda (to get a 1% solution). So out of the intestines are derived
toxic metabolites. In addition, by feces excreted or
colored water can be seen in time for signs of bleeding and
take action.

Treatment of chronic liver failure in the stage
subcompensation and compensation is complemented by hardware methods:
plasma exchange and hemosorption. Patient put on record for transplant
plot donor liver. All the waiting time he must comply
strict diet, do not drink alcohol, drink sorbents, lactulose,
drugs-hepatoprotectors (“Heptral”).

Acute hepatic encephalopathy and decompensated chronic
encephalopathy liver transplantation does not cure: during surgery,
despite the transfused plasma is likely to begin
severe bleeding that will lead to death. In these
Alternative treatments can be given for conditions:
intravenous stem cells, tissue oxygenation
by introducing “blue blood” – solution “Perftoran.” With
viral and autoimmune hepatitis are prescribed corticosteroid
hormones – to suppress hyperactive immunity, which in
trying to get rid of the virus (or antigen) destroys its own
liver. In addition, these hormones reduce the degree of brain edema, which
necessary for hepatic encephalopathy.

Автор: Кривега Мария Салаватовна врач-реаниматолог

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