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  3. Gastroenterology and Hepatology

Major points

  1. Hepatic encephalopathy is a change in the state of consciousness caused by an increase in the ammonia level in the blood. In severe cases, there will be a coma.
  2. Common symptoms are stupor, flapping tremor and lethargy.
  3. Use oral or rectal laxatives to maintain bowel movements of 2-3 times per day.
  4. Prevention methods include: quitting smoking and drinking, taking plant-based protein, and avoiding constipation.
 
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. Use oral or rectal laxatives such as lactulose to maintain a bowel movement of 2-3 times per day.    
  2. Remove the risk factor or precipitant, such as infection, bleeding, and alcohol consumption.
  3. Avoid taking too much protein and choose suitable foods according to the advice of a nutritionist.
 
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. Regularly follow-up with a visit to an outpatient clinic at your doctor’s instructions. 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.
 
Reference
  1. Blaney, H., & DeMorrow, S. (2022). Hepatic encephalopathy: Thinking beyond ammonia. Clinical Liver Disease, 19(1), 21-24. https://doi.org/10.1002/cld.1163
  2. Feng, R.F., & Guo S. F. (2019). Nursing of liver cirrhosis. In Wang G. Y(Ed.), New Medical Surgical Nursing (6th ed., pp.1069-1087). Yongda.
  3. Häussinger, D., Butz, M., Schnitzler, A., & Görg, B. (2021). Pathomechanisms in hepatic encephalopathy. Biological Chemistry, 402(9), 1087-1102. https://doi.org/10.1515/hsz-2021-0168
  4. Montagnese, S., Russo, F. P., Amodio, P., Burra, P., Gasbarrini, A., Loguercio, C., Marchesini, G., Merli, M., Ponziani, F. R., Riggio, O., & 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: Official Journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver, 51(2), 190-205. https://doi.org/10.1016/j.dld.2018.11.035
  5. 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. https://doi.org/10.1016/j.cld.2019.07.001
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    Taipei Veterans General Hospital 
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    • Smoking and chewing betel nut significantly induce oral cancer. Obesity will potentially increase the risk of breast cancer and colorectal cancer. Please control body weight and keep away from tobacco and betel nut.
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