Encephalopathy is also known as hepatic encephalopathy or portosystemic encephalopathy (PSE).
Description
Encephalopathy is a reversible change in mental status in which toxins that come from digestive processes are not filtered and removed properly by the liver. These toxins reach the bloodstream leading to the brain. This can result in an altered mental status referred to as encephalopathy.
Causes
In almost all cases, encephalopathy is caused by blood bypassing the liver due to cirrhosis. These toxins eventually accumulate within the brain and cause encephalopathy. There are many toxins involved and the process is not completely understood. The most commonly measured blood test to evaluate encephalopathy is ammonia. The best test for encephalopathy is a mental and physical exam.
Symptoms
Encephalopathy can cause mood changes, confusion, disorientation, trouble with muscle movements, and in extreme cases, coma. Your health care provider may ask you to hold out your hands to see if a “liver flap” is present. The medical term for these involuntary movements is asterixis. This condition is usually intermittently present. But once you have been diagnosed with encephalopathy, you are always at risk for these episodes.
Safety note:
Encephalopathy may interfere with your ability to drive safely or operate potentially dangerous machinery. You may be asked to stop driving.
Treatments for encephalopathy
The only way to cure encephalopathy is to fix the underlying liver problem. Frequently, this is not possible, so people need to know how to manage and minimize their bouts of encephalopathy.
Management of encephalopathy
The management of encephalopathy is based on dietary changes and medications.
Dietary changes:
- Avoid eating red meat.
- Eat 80 grams of protein a day. Sources of protein include soy beans, tofu, beans, legumes, and fish. Diets too low in protein (40 - 60 grams/day) may be dangerous because they can decrease muscle mass. Temporary reduction or even elimination of protein from the diet may be necessary in severe flareups.
Medications to avoid
The most important medications to avoid are those that cause sleepiness, such as medications used to treat anxiety or pain (e.g., Valium [diazepam], Vicodin [hydrocodone]), and many others.
Medications for treatment
Lactulose
Lactulose is a non-absorbable sugar that changes the acidity of the colon and decreases the amount of ammonia and other toxins into the blood. This medication may cause loose bowel movements or diarrhea. Lactulose is most effective if the patient has two to three bowel movements each day. If the patient has more than four bowel movements, he or she can decrease the lactulose dose by one-third. The patient should make dose adjustments at home. If diarrhea continues after lactulose is stopped, a stool evaluation should be performed.
Antibiotics
Flagyl (Metronidazole)
Metronidazole is an oral antibiotic that changes the colonic and intestinal bacteria. Side effects include an “antabuse” reaction (do not drink alcohol or use medications that contain alcohol with this medication) and nervous system reactions, including confusion and nerve tingling.
Neomycin
Neomycin is an antibiotic that also changes the bacteria in the intestine and decreases the amount of ammonia and other toxins released into the blood. This medication is usually given at a dose of 500 mg four times a day. If this medication is prescribed for more than six months, hearing tests should be performed, since there may be a risk of hearing loss. Hearing tests are critical if a patient is using Lasix (Furosemide) in conjunction with neomycin.
Rifaximin (Xifaxan)
Rifaximin is an antibiotic that changes the chemistry and bacteria in the intestine and decreases the amount of ammonia and other toxins released into the blood. The dosage is usually 200 mg one to three times per day. It may cause headache, skin rash, or unusual ringing in the ears. It is very expensive and not necessarily better than other antibiotics.
Zinc
Your blood may be tested for zinc. Zinc levels may be low in some patients with chronic liver disease and particularly if you are taking water pills. A deficiency of zinc worsens encephalopathy. Zinc supplements are available through pharmacies or health food stores. Patients with zinc deficiencies should take between 50 and 200 mg per day.
Notes
Encephalopathy may be the presenting sign of an infection or a gastrointestinal bleed. Any worsening of encephalopathy should be evaluated.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 11/15/2005
