What is hepatic encephalopathy?
Hepatic encephalopathy is a condition of neuropsychiatric abnormalities following the change of consciousness in patients with underlying acute or chronic liver dysfunctional diseases such as liver cirrhosis and liver failure. Liver dysfunction results in the accumulation of protein metabolites that increase the level of blood ammonia. Factors associated with hepatic encephalopathy include upper gastrointestinal tract bleeding, infection, constipation, taking high-protein food, improper use of diuretics, electrolyte imbalance, sedative hypnotic drug abuse, and excessive drinking.
Clinical presentations and grading of hepatic encephalopathy:
  1. Grade I: confusion - change in behavior, slurred speech, disturbed sleep, exhaustion, personality change, memory impairment, attention deficit.
  2. Grade II: drowsiness - messy handwriting, lethargy, flapping tremor (a tremor of the hand when the wrist is extended).
  3. Grade III: semicoma -fetor hepaticus (odor of acetone in the patient’s mouth), sleeping all the time, but capable of being woken up.
  4. Grade IV: coma - no response to pain. 
Other medical conditions might have the above symptoms, which are not necessarily related to hepatic encephalopathy. If you have the symptoms mentioned above, please seek medical attention.
Treatment of hepatic encephalopathy:
  1. Remove the risk factor or precipitant, such as infection, bleeding, and alcohol consumption.     
  2. Limit protein intake.  
  3. Use oral or rectal laxatives such as lactulose to maintain a bowel movement of 2-3 times per day.
Lifestyle modification:
  1. Diet: avoid alcohol drinks, reduce high salt and high protein foods, and decrease eating of sausage, ham, etc. Get protein from vegetables, eat high-fiber foods, and take a probiotics supplement to regulate intestinal flora.
  2. Maintain a regular lifestyle and exercise as you can, but beware of safety. 
  3. Prevent constipation. Maintain a bowel movement 2-3 times per day.
  4. Take medicine properly under doctor’s prescription. Do not take sedative drugs without doctor’s advice.
  5. Reduce access to public places as best as possible. If visiting a public place is necessary, wear a mask to prevent infections. 
  6. When consciousness changes, or flapping tremor appears, it could be the sign of early hepatic encephalopathy. Please visit a doctor as soon as possible for further examination.
  7. Regularly follow-up with a visit to an outpatient clinic at your doctor’s instructions.
  1. Feng, R. F., Lee, H. L., Fang, Y. Y., Wu, L. B., Chou, H. L., Liu, L. N., … Hsieh, C. J. (2018). Nursing management of liver disorders. In H. E. Liu (Ed.), Adult Health Nursing (7th ed., pp. 448-485). Taipei City, Taiwan, ROC: Farseeing.
  2. Hörner, D. V., Avery, A., & Stow, R. (2017). The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy: A systematic review. Journal of Clinical Gastroenterology, 51(4),312-323. doi:10.1097/MCG.0000000000000789
  3. Montagnese, S., Russo, F. P., Amodio, P., Burra, P., Gasbarrini, A., Loguercio, C., … Scarpignato, C. (2019). Hepatic encephalopathy 2018: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF). Digestive and Liver Disease, 51(2), 190-205. doi:10.1016/j.dld.2018.11.035
  4. Yanny, B., Winters, A., Boutros, S., & Saab, S. (2019). Hepatic encephalopathy challenges, burden, and diagnostic and therapeutic approach. Clinics in Liver Disease, 23(4), 607-623. doi:10.1016/j.cld.2019.07.001
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