The clinical picture of hepatic encephalopathy, treatment and prevention methods
- 1 Characteristic
- 2 Development mechanism
- 3 Symptoms
- 4 Diagnostics
- 5 First aid
- 6 Treatment
- 7 Complications
- 8 Prevention
In acute form, the disease develops rapidly, often irreversibly, leading to death. In the ordinary course, the dynamics are progressive and amenable to correction.
Hepatic encephalopathy is a condition characterized by damage to the central nervous system, which occurs against the background of liver dysfunctions and the metabolic disorder caused by them. Abuse leads diuretic, alcohol, some diseases. Sometimes it is possible a rapid course that takes the life of a patient in a few days. The causes of the acute process are hepatitis, poisoning, the formation of blood clots in the hepatic veins.
The detailed mechanism of the onset of pathology is not fully revealed.
The disease is accompanied by anatomical, physiological and psychological disorders. Brain cells and connections between them are destroyed, the functioning of vessels, internal organs is disturbed. Intellect, memory deteriorates, personality traits change. The thermal stage of the disorder ends with hepatic coma.
Currently, the mechanism leading to liver encephalopathy is based on the negative effects of ammonia and other metabolic products on astrocytes – brain cells. This type of cell regulates the composition of the extracellular fluid, protects neurons from exposure to harmful substances, controls blood flow and, if necessary, has the ability to transform into nerve cells. Ammonia, pseudo-mediators, amino acids, carbohydrate and fat metabolites disrupt the function of astrocytes, have a negative effect on the transmission of inhibition and excitation, leading to an increase in intracranial pressure and the appearance of brain edema.
Ammonia enters the liver through the portal vein or portocaval anastomoses. The dysfunction of this organ reduces the speed and quality of the processing of hydrogen nitrite and mitigates its toxic properties. Further, with the bloodstream, the substance enters the kidneys. Here, against the background of a metabolic disorder, its accumulation, partial processing and release into the arteries leading to the brain occurs. After entering the brain, ammonia violates the chemical balance and causes intoxication.
It is likely that electrolyte, acid-base metabolic disorders and a high content of nitrogenous compounds in the blood also lead to encephalopathy. Brain intoxication is caused by residues of drugs accumulating in the liver.
The main cause of hepatic encephalopathy is a metabolic disorder. Provoke him:
- drug intoxication;
- gastrointestinal bleeding;
- narcotic poisoning;
Read also … Alcoholic encephalopathy as a result of alcohol dependence
Among the factors leading to the launch of pathology, isolated long-term constipation, infectious diseases, alcohol consumption, drug or drug overdose, surgery, eating foods that contain a lot of protein.
It is customary to speak of several groups of manifestations of hepatic encephalopathy. First of all, pay attention to changes in behavior. Patients often get annoyed. Periods of apathy and depression are replaced by joy and even euphoria. The prolonged effect on the brain of intoxication leads to aggressive behavior, actions that the patient himself cannot explain, and actions that do not correspond to the situation.
A person with pleasure communicates with unfamiliar or unfamiliar people, without showing interest and attention to relatives and friends. As the disease progresses, friendliness gives way to aggressiveness and isolation.
Signs of declining intelligence appear fairly quickly. The patient loses the ability to concentrate and logical thinking, suffers memory, speech. Skills of work activity, writing disappear.
Movement become sweeping, chaotic. When muscle tension occurs, involuntary twitching of the limbs is observed.
Hepatic sweetish smell from the mouth appears, tenderness in the right hypochondrium and heaviness in the left. Mucous and skin become jaundiced. Constant fluctuations in temperature are possible.
The degree of manifestation depends on the type of provoking factor, the nature of the pathology. Special stages are peculiar to different stages.
Based on the reasons there are 3 types of the disease. If the basis of the disease is acute liver failure caused by inflammation, poisoning, malignant tumors, they say about type A.
The ingress of toxins from the intestines into the bloodstream and their effect on nerve cells allows to identify type B. The main causes of this type are the consumption of protein foods and the rapid change in the intestinal microflora. The latter type C is associated with impaired blood supply to the liver.
Features of the course of the disease suggest the existence of acute, subacute and chronic forms. Acute pathology arises unexpectedly, lasts several hours or days. The state is rapidly changing, the state of coma is rapidly approaching.
The main reason for this dynamic is toxic, viral or drug-induced hepatitis. In the subacute form, the disease develops slowly, the symptoms appear within a week or two. Characterized by recurrent.
Chronic form occurs due to cirrhosis, accompanied by an increase in pressure in the portal vessels. Accompanied by distraction, frequent mood swings, deterioration of cognitive functions. Tremor appears, muscle stiffness is noted. Lasts a few years.
Detection of a specific composition of symptoms allows us to talk about 5 degrees of the disease:
- Latent stage Under normal conditions, it is impossible to suspect the presence of the disease. Its symptoms manifest under stress, strong emotional stress. At this stage, there are irregularities in the performance of psychometric tests.
- The first stage. There is marked insomnia at night, alternating with sleepiness overcoming the patient during the day. The concentration of attention decreases, the tendency to repeat the same words is noticeable, hectic, constant search for some one thing. There is a change of mood, depression, alternating with excitement and euphoria. A person becomes irritable, tearful, anxious. There are signs of a violation of the account, thinking, ability to perform the simplest mathematical tasks. The patient may complain of lack of appetite, the appearance of bitter taste in the mouth, nausea. Strange ringing can appear in the ears, before the sight of a fly. Possible lack of coordination of movements and handwriting. Sometimes there is an increase in pupils.
- Second stage There is a further decrease in intelligence, memory. Speech becomes slurred, slow, monotonous. There are signs of disorientation in time and on site. In behavior, there are more and more actions performed with an incomprehensible purpose. The patient may appear hallucinations, aggression. Emotional background is lowered, apathy appears more and more often accompanied by a feeling of melancholy, hopelessness, desire to leave. Possible fainting, twitching of the muscles of the face, cramps of the limbs. Breathing quickens. In the mouth there is the smell of the liver, the skin becomes jaundiced.
- The third stage. A person loses more and more a sense of time and place. Characterized by depression, drowsiness, stunned state. Consciousness is filled with hallucinations. The patient may be agitated in bright light, harsh sounds, severe pain. However, he practically does not respond to the appeal to him. Speech is strongly disturbed, incomprehensible. Muscle hypertonus, trembling of the extremities is noted. At this stage it is not possible to perform any psychometric tests. On palpation, a reduced liver size is found. Yellowness is enhanced, the face becomes like a mask. The muscles are rigid, convulsions, trembling appear. Pupils are enlarged. Observed involuntary reflexes.
- Fourth stage. Call it also thermal. There is a risk of hepatic coma, the patient does not respond to treatment, light, pain, sounds. Pupils narrowed. Observed rapid shallow breathing. Reflexes and the functioning of organs and their systems are reduced. People die without coming to their senses.
The main purpose of diagnostic measures is to confirm the presence of the disease, to determine its causes, features and stage.
In a conversation with a patient, the doctor collects information about his troubling phenomena, a history of liver diseases, and medications taken. A specialist assigns a consultation to a gastroenterologist and neuropathologist, general and biochemical blood test, coagulogram, test for hepatitis markers. Studies will reveal the presence of inflammation, determine the level of blood clotting, urea, alkaline phosphatase, creatinine, and other elements.
The degree of organ damage is determined by ultrasound diagnostics of the gallbladder and liver, MRI and CT. Studies show a change in the size of the body, foci of extinction and atrophy. The cause of the pathology is detected by performing a biopsy. Usually it is performed under the control of ultrasound, because the procedure for cirrhosis can be dangerous. The electroencephalogram will allow you to assess how affected the brain is. In some cases, a puncture of the cerebrospinal fluid is taken to check the protein level.
Hepatic encephalopathy should be delimited from diseases that have similar symptoms: neuroinfection, metabolic disorders, bleeding in the brain, alcoholic encephalopathy.
A neuropathologist or psychiatrist conducts psychometric testing, including the study of motility and cognitive reaction rate.
Emergency care should be provided to the patient with the manifestation of symptoms of hepatic coma. Need to:
- fix the onset of the attack and report it to the doctor;
- lay a man on his side;
- air the room;
- clear vomiting of the mouth;
- give constantly clean water.
In case of excessive arousal, injection of 1% Dimedrol in a volume of 2 ml is indicated. For the normalization of cardiovascular activity do a shot of Cordiamin or Methason.
The therapeutic tactics are determined by the doctor, most often it is a gastroenterologist or a hepatologist. When processes affecting the central nervous system occur, the treatment of hepatic encephalopathy is complemented by a neuropathologist or psychiatrist.
Selection of drugs and methods of treatment depends on the cause of the pathology, the factors that caused it, the degree of violation. Therapy is complex, it includes drugs aimed at eliminating nitrogenous substances in the blood, reducing ammonia levels, cleansing the intestines, reducing intoxication. In severe cases, surgical treatment.
In acute and subacute condition the following drugs are prescribed:
- To reduce the level of ammonia, reduce its absorption, splitting acids, diluting the stool, lactulose is prescribed (Duphalac, Lactitol). At the first stage, it causes frustration, and after a while regular soft stools two to three times a day. In severe cases, the drug is administered through a probe.
- In case of insufficient effect from taking lactulose, antibacterial agents are prescribed. Their action is aimed at suppressing the formation of ammonia by the intestinal microflora. Neomination is used at a dosage of 2 to 6 g per day. In case of intestinal obstruction, it is administered through an enema. Long-term use causes renal dysfunction. Rifaximin is administered one tablet 3 times a day. Treat need to for 7 days, after a break. Resume taking the drug no earlier than 1 month. It is completely absorbed in the intestines and is aimed at combating pathogenic bacteria. May cause constipation.
- Of antibiotics, Vancomycin is indicated. The drug is administered intravenously or intramuscularly. Metronidazole is prescribed with caution, since it is excreted mainly through the liver.
In most cases, parallel treatment with antibiotics and lactulose. However, before the appointment, it is recommended to check the pH level, since when the indicator is above 5, antibiotics can adversely affect lactulose.
Blood clotting disorders, often accompanying hepatic pathologies, are carried out with the use of Heparin, fibrinolytics, antiprotease. The risk of cerebral edema is reduced by prednisone or dexamethasone.
In the tactics of treating a chronic disease, reduced protein intake plays an important role. The daily rate should be 20-50 g. To fill up the energy requirement, glucose is prescribed. With an increased tendency to bleeding, therapy with fresh frozen plasma is prescribed.
Intoxication with ammonia and nitrogenous substances is eliminated by Dufalac, antibiotics, Essentiale, sodium preparations, sodium benzoate, amino acids. In severe cases, plasmapheresis is indicated. Flumazenil is prescribed to reduce benzodeapins.
The main methods of surgical treatment are:
- Portal shunting. A shunt is installed to ensure bypass flow. As a result, the blood pressure in the portal vein decreases, the likelihood of hypertension in local vessels decreases, stable blood supply is ensured.
- Organ transplant. It is performed if the hepatic pathology is irreversible, and drug treatment is ineffective.
The processes occurring on the latent, first and second stages are reversible. Delay in the diagnosis and treatment of pathology leads to brain edema, stroke, paralysis, purulent-septic infection, diseases of the kidneys and pancreas.
Preventive measures will help prevent hepatic encephalopathy and reduce its severity. These include:
- rational diet with restricted protein intake;
- refusal of uncontrolled medication;
- timely treatment of liver diseases;
- stopping alcohol intake;
- the use of phosphate enemas to clean the intestines;
- timely treatment of constipation.
Hepatic encephalopathy has a negative prognosis if the patient ignores her symptoms and refuses timely diagnosis and treatment.. It affects all areas of a person’s personality and life. Properly prescribed therapy and compliance with preventive measures will help improve the prognosis and quality of life of the patient.