BACK TOTOP Browse A-ZSearchBrowse A-ZABCDEFGHIJKLMNOPQRSTUVWXYZ0-9 E-mail FormEmail ResultsName:Email address:Recipients Name:Recipients address:Message: Print-FriendlyBookmarksbookmarks-menuLoss of brain function - liver diseaseHepatic coma; Encephalopathy - hepatic; Hepatic encephalopathy; Portosystemic encephalopathyLoss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem may occur suddenly or it may develop slowly over time. Causes An important function of the liver is to make toxic substances in the body harmless. These substances may be made by the body (ammonia), or substances that you take in (medicines).When the liver is damaged, these "poisons" can build up in the bloodstream and affect the function of the nervous system. The result may be HE.HE can occur suddenly and you may become ill very quickly. Causes of HE may include:Hepatitis A or B infection (uncommon to occur this way) Blockage of blood supply to the liver Poisoning by different toxins or medicines Constipation Upper gastrointestinal bleedingPeople with severe liver damage often suffer from HE. The end result of chronic liver damage is cirrhosis. Common causes of chronic liver disease are:Severe hepatitis B or C infection BHepatitis B is irritation and swelling (inflammation) of the liver due to infection with the hepatitis B virus (HBV). Other types of viral hepatitis ...Read Article Now Book Mark Article CHepatitis C is a viral disease that leads to swelling (inflammation) of the liver. Other types of viral hepatitis include:Hepatitis AHepatitis BHepat...Read Article Now Book Mark Article Alcohol abuse Alcohol abuseAlcohol use disorder is when your drinking causes serious problems in your life, yet you keep drinking. You may also need more and more alcohol to f...Read Article Now Book Mark Article Autoimmune hepatitis AutoimmuneAutoimmune hepatitis causes inflammation of the liver. It occurs when immune cells mistake the liver's normal cells for harmful invaders and attack ...Read Article Now Book Mark Article Bile duct disorders Some medicines Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)Once you have liver damage, episodes of worsening brain function may be triggered by:Loss of body fluids (dehydration) Eating too much protein Low blood potassium or sodium levels Bleeding in the intestines, stomach, or food pipe (esophagus) Infections Kidney problems Low oxygen levels in the body Shunt placement or complications Surgery Narcotic pain or sedative medicinesDisorders that can appear similar to HE may include:Alcohol intoxication Alcohol withdrawal Bleeding inside the skull (subdural hematoma) Subdural hematomaA subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain.Read Article Now Book Mark Article Brain disorder caused by lack of vitamin B1 (Wernicke-Korsakoff syndrome)Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome is a brain disorder due to vitamin B1 (thiamine) deficiency.Read Article Now Book Mark Article In some cases, HE is a short-term problem that can be corrected. It may also occur as part of a long-term (chronic) problem from liver disease that gets worse over time. Symptoms Symptoms of HE are graded on a scale of grades 1 to 4. They may begin slowly and worsen over time.Early symptoms may be mild and include:Breath with a musty or sweet odor Changes in sleep patterns Changes in thinking Mild confusion Forgetfulness Personality or mood changes Poor concentration and judgment Worsening of handwriting or loss of other small hand movementsSevere symptoms may include:Abnormal movements or shaking of hands or arms Agitation, excitement, or seizures (occur rarely) Disorientation Drowsiness or confusion Behavior or personality changes Slurred speech Slowed or sluggish movementPeople with HE can become unconscious, unresponsive, and possibly enter into a coma.People are often not able to care for themselves because of these symptoms. Exams and Tests Signs of nervous system changes may include:Shaking of the hands ("flapping tremor" or asterixis) when trying to hold arms in front of the body and lift the hands Problems with thinking and doing mental tasks Signs of liver disease, such as yellow skin and eyes (jaundice) and fluid collection in the abdomen (ascites) Liver diseaseThe term "liver disease" applies to many conditions that stop the liver from working or prevent it from functioning well. Abdominal pain or swelling...Read Article Now Book Mark Article AscitesAscites is the build-up of fluid in the space between the lining of the abdomen and abdominal organs.Read Article Now Book Mark Article Musty odor to the breath and urineTests done may include:Complete blood count or hematocrit to check for anemia CT scan of the head or MRI CT scan of the headA head computed tomography (CT) scan uses many x-rays to create pictures of the head, including the skull, brain, eye sockets, and sinuses.Read Article Now Book Mark Article MRIA head MRI (magnetic resonance imaging) is an imaging test that uses powerful magnets and radio waves to create pictures of the brain and surrounding...Read Article Now Book Mark Article EEG EEGAn electroencephalogram (EEG) is a test to measure the electrical activity of the brain.Read Article Now Book Mark Article Liver function tests Liver function testsLiver function tests are common tests that are used to see how well the liver is working. Tests include:AlbuminAlpha-1 antitrypsinAlkaline phosphata...Read Article Now Book Mark Article Prothrombin time Prothrombin timeProthrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. It measures the functio...Read Article Now Book Mark Article Serum ammonia level in the blood Sodium level in the blood Sodium level in the bloodThe sodium blood test measures the concentration of sodium in the blood. Sodium can also be measured using a urine test.Read Article Now Book Mark Article Potassium level in the blood Potassium level in the bloodThis test measures the amount of potassium in the fluid portion (serum) of the blood. Potassium (K+) helps nerves and muscles communicate. It also ...Read Article Now Book Mark Article BUN (blood urea nitrogen) and blood creatinine to see how the kidneys are working BUNBUN stands for blood urea nitrogen. Urea nitrogen is what forms when protein breaks down. A test can be done to measure the amount of urea nitrogen ...Read Article Now Book Mark Article CreatinineThe creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys are working. Creatinine in t...Read Article Now Book Mark Article Treatment Treatment of HE depends upon the cause.If changes in brain function are severe, a hospital stay may be needed.Bleeding in the digestive tract must be stopped. Infections, kidney failure, and changes in sodium and potassium levels need to be treated. Medicines are given to help lower ammonia level and improve brain function. Medicines given may include:Lactulose to prevent bacteria in the intestines from creating ammonia. It may cause diarrhea. Neomycin and rifaximin also reduce the amount of ammonia made in the intestines. If the HE improves while taking rifaximin, it should be continued indefinitely. You should avoid:Any sedatives, tranquilizers, and any other medicines that are broken down by the liver Medicines containing ammonium (including certain antacids) Your health care provider may suggest other medicines and treatments. These may have varying results. Outlook (Prognosis) The outlook of HE depends on the management of the cause of HE. Chronic forms of the disorder often continue to get worse and come back.The first two stages of the disease have a good prognosis. Stage three and four have a poor prognosis. When to Contact a Medical Professional Contact your provider if you or people around you notice any problems with your mental state or nervous system function. This is important for people who already have a liver disorder. HE can get worse quickly and become an emergency condition. Prevention Treating liver problems may prevent HE. Avoiding alcohol and intravenous drugs can prevent many liver disorders.Open ReferencesReferencesCameron J. Portal hypertension. In: Cameron J, ed. Current Surgical Therapy. 14th ed. Philadelphia, PA: Elsevier; 2023:413-456.Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Cooney KA, eds. Goldman-Cecil Medicine. 27th ed. Philadelphia, PA: Elsevier; 2024:chap 139.Mehta SS, Fallon MB. Hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, and other systemic complications of liver disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 94.Wong MP, Moitra VK. Hepatic encephalopathy. In: Fleisher LA, Roizen MF, Roizen JD, eds. Essence of Anesthesia Practice. 4th ed. Philadelphia, PA: Elsevier; 2018:198-198.AllVideoImagesTogA Closer Look Cirrhosis(Alt. Medicine)Alzheimer disease(Alt. Medicine)Cirrhosis - InDepth(In-Depth)Brain tumors - primary - InDepth(In-Depth)Viral hepatitis(Alt. Medicine)Parkinson disease - InDepth(In-Depth)Sickle cell disease - InDepth(In-Depth)Atherosclerosis(Alt. Medicine)Weight control and diet - InDepth(In-Depth)Stroke - InDepth(In-Depth)Self Care Daily bowel care program Tests for Loss of brain function - liver disease Vitamin B12 levelRelated Information Decreased alertness(Symptoms)Cirrhosis(Condition)Hepatitis(Condition)Ammonia poisoning(Poison)Protein in diet(Nutrition)Electrolytes(Special Topic)Abdominal tap (Medical Test)Alkalosis(Condition)Alcohol use disorder(Condition)Alcohol withdrawal(Condition)Cirrhosis - InDepth(In-Depth)Hepatitis - InDepth(In-Depth)Alcohol use disorders - InDepth(In-Depth) Review Date: 8/7/2023 Reviewed By: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. No warranty of any kind, either expressed or implied, is made as to the accuracy, reliability, timeliness, or correctness of any translations made by a third-party service of the information provided herein into any other language. © 1997- A.D.A.M., a business unit of Ebix, Inc. Any duplication or distribution of the information contained herein is strictly prohibited. © 1997- All rights reserved. A.D.A.M. content is best viewed in IE9 or above, Firefox and Google Chrome browser.Content is best viewed in IE9 or above, Firefox and Google Chrome browser.
Loss of brain function - liver diseaseHepatic coma; Encephalopathy - hepatic; Hepatic encephalopathy; Portosystemic encephalopathyLoss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem may occur suddenly or it may develop slowly over time. Causes An important function of the liver is to make toxic substances in the body harmless. These substances may be made by the body (ammonia), or substances that you take in (medicines).When the liver is damaged, these "poisons" can build up in the bloodstream and affect the function of the nervous system. The result may be HE.HE can occur suddenly and you may become ill very quickly. Causes of HE may include:Hepatitis A or B infection (uncommon to occur this way) Blockage of blood supply to the liver Poisoning by different toxins or medicines Constipation Upper gastrointestinal bleedingPeople with severe liver damage often suffer from HE. The end result of chronic liver damage is cirrhosis. Common causes of chronic liver disease are:Severe hepatitis B or C infection BHepatitis B is irritation and swelling (inflammation) of the liver due to infection with the hepatitis B virus (HBV). Other types of viral hepatitis ...Read Article Now Book Mark Article CHepatitis C is a viral disease that leads to swelling (inflammation) of the liver. Other types of viral hepatitis include:Hepatitis AHepatitis BHepat...Read Article Now Book Mark Article Alcohol abuse Alcohol abuseAlcohol use disorder is when your drinking causes serious problems in your life, yet you keep drinking. You may also need more and more alcohol to f...Read Article Now Book Mark Article Autoimmune hepatitis AutoimmuneAutoimmune hepatitis causes inflammation of the liver. It occurs when immune cells mistake the liver's normal cells for harmful invaders and attack ...Read Article Now Book Mark Article Bile duct disorders Some medicines Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)Once you have liver damage, episodes of worsening brain function may be triggered by:Loss of body fluids (dehydration) Eating too much protein Low blood potassium or sodium levels Bleeding in the intestines, stomach, or food pipe (esophagus) Infections Kidney problems Low oxygen levels in the body Shunt placement or complications Surgery Narcotic pain or sedative medicinesDisorders that can appear similar to HE may include:Alcohol intoxication Alcohol withdrawal Bleeding inside the skull (subdural hematoma) Subdural hematomaA subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain.Read Article Now Book Mark Article Brain disorder caused by lack of vitamin B1 (Wernicke-Korsakoff syndrome)Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome is a brain disorder due to vitamin B1 (thiamine) deficiency.Read Article Now Book Mark Article In some cases, HE is a short-term problem that can be corrected. It may also occur as part of a long-term (chronic) problem from liver disease that gets worse over time. Symptoms Symptoms of HE are graded on a scale of grades 1 to 4. They may begin slowly and worsen over time.Early symptoms may be mild and include:Breath with a musty or sweet odor Changes in sleep patterns Changes in thinking Mild confusion Forgetfulness Personality or mood changes Poor concentration and judgment Worsening of handwriting or loss of other small hand movementsSevere symptoms may include:Abnormal movements or shaking of hands or arms Agitation, excitement, or seizures (occur rarely) Disorientation Drowsiness or confusion Behavior or personality changes Slurred speech Slowed or sluggish movementPeople with HE can become unconscious, unresponsive, and possibly enter into a coma.People are often not able to care for themselves because of these symptoms. Exams and Tests Signs of nervous system changes may include:Shaking of the hands ("flapping tremor" or asterixis) when trying to hold arms in front of the body and lift the hands Problems with thinking and doing mental tasks Signs of liver disease, such as yellow skin and eyes (jaundice) and fluid collection in the abdomen (ascites) Liver diseaseThe term "liver disease" applies to many conditions that stop the liver from working or prevent it from functioning well. Abdominal pain or swelling...Read Article Now Book Mark Article AscitesAscites is the build-up of fluid in the space between the lining of the abdomen and abdominal organs.Read Article Now Book Mark Article Musty odor to the breath and urineTests done may include:Complete blood count or hematocrit to check for anemia CT scan of the head or MRI CT scan of the headA head computed tomography (CT) scan uses many x-rays to create pictures of the head, including the skull, brain, eye sockets, and sinuses.Read Article Now Book Mark Article MRIA head MRI (magnetic resonance imaging) is an imaging test that uses powerful magnets and radio waves to create pictures of the brain and surrounding...Read Article Now Book Mark Article EEG EEGAn electroencephalogram (EEG) is a test to measure the electrical activity of the brain.Read Article Now Book Mark Article Liver function tests Liver function testsLiver function tests are common tests that are used to see how well the liver is working. Tests include:AlbuminAlpha-1 antitrypsinAlkaline phosphata...Read Article Now Book Mark Article Prothrombin time Prothrombin timeProthrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. It measures the functio...Read Article Now Book Mark Article Serum ammonia level in the blood Sodium level in the blood Sodium level in the bloodThe sodium blood test measures the concentration of sodium in the blood. Sodium can also be measured using a urine test.Read Article Now Book Mark Article Potassium level in the blood Potassium level in the bloodThis test measures the amount of potassium in the fluid portion (serum) of the blood. Potassium (K+) helps nerves and muscles communicate. It also ...Read Article Now Book Mark Article BUN (blood urea nitrogen) and blood creatinine to see how the kidneys are working BUNBUN stands for blood urea nitrogen. Urea nitrogen is what forms when protein breaks down. A test can be done to measure the amount of urea nitrogen ...Read Article Now Book Mark Article CreatinineThe creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys are working. Creatinine in t...Read Article Now Book Mark Article Treatment Treatment of HE depends upon the cause.If changes in brain function are severe, a hospital stay may be needed.Bleeding in the digestive tract must be stopped. Infections, kidney failure, and changes in sodium and potassium levels need to be treated. Medicines are given to help lower ammonia level and improve brain function. Medicines given may include:Lactulose to prevent bacteria in the intestines from creating ammonia. It may cause diarrhea. Neomycin and rifaximin also reduce the amount of ammonia made in the intestines. If the HE improves while taking rifaximin, it should be continued indefinitely. You should avoid:Any sedatives, tranquilizers, and any other medicines that are broken down by the liver Medicines containing ammonium (including certain antacids) Your health care provider may suggest other medicines and treatments. These may have varying results. Outlook (Prognosis) The outlook of HE depends on the management of the cause of HE. Chronic forms of the disorder often continue to get worse and come back.The first two stages of the disease have a good prognosis. Stage three and four have a poor prognosis. When to Contact a Medical Professional Contact your provider if you or people around you notice any problems with your mental state or nervous system function. This is important for people who already have a liver disorder. HE can get worse quickly and become an emergency condition. Prevention Treating liver problems may prevent HE. Avoiding alcohol and intravenous drugs can prevent many liver disorders.Open ReferencesReferencesCameron J. Portal hypertension. In: Cameron J, ed. Current Surgical Therapy. 14th ed. Philadelphia, PA: Elsevier; 2023:413-456.Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Cooney KA, eds. Goldman-Cecil Medicine. 27th ed. Philadelphia, PA: Elsevier; 2024:chap 139.Mehta SS, Fallon MB. Hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, and other systemic complications of liver disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 94.Wong MP, Moitra VK. Hepatic encephalopathy. In: Fleisher LA, Roizen MF, Roizen JD, eds. Essence of Anesthesia Practice. 4th ed. Philadelphia, PA: Elsevier; 2018:198-198.