Loss of brain function - liver diseaseHepatic coma; Encephalopathy - hepatic; Hepatic encephalopathy; Portosystemic encephalopathy
Loss 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.
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
- Upper gastrointestinal bleeding
People 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
Hepatitis 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
Hepatitis 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 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
Autoimmune hepatitis is inflammation of the liver. It occurs when immune cells mistake the liver's normal cells for harmful invaders and attack them...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:
- Less body fluids (dehydration)
- Eating too much protein
- Low potassium or sodium levels
- Bleeding from the intestines, stomach, or food pipe (esophagus)
- Kidney problems
- Low oxygen levels in the body
- Shunt placement or complications
- Narcotic pain or sedative medicines
Disorders that can appear similar to HE may include:
- Alcohol intoxication
- Alcohol withdrawal
- Bleeding under the skull (subdural hematoma)
A 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 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 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
- Personality or mood changes
- Poor concentration and judgment
- Worsening of handwriting or loss of other small hand movements
Severe symptoms may include:
- Abnormal movements or shaking of hands or arms
- Agitation, excitement, or seizures (occur rarely)
- Drowsiness or confusion
- Behavior or personality changes
- Slurred speech
- Slowed or sluggish movement
People 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") 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)
The 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
Ascites 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 urine
Tests done may include:
- Complete blood count or hematocrit to check for anemia
- CT scan of the head or MRI
CT scan of the head
A 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
A 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
An electroencephalogram (EEG) is a test to measure the electrical activity of the brain.Read Article Now Book Mark Article
- Liver function tests
Liver function tests
Liver 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 time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. A related blood test is ...Read Article Now Book Mark Article
- Serum ammonia level
- Sodium level in the blood
Sodium level in the blood
The 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 blood
This 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 creatinine to see how the kidneys are working
BUN 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
The creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys are working. Creatinine can ...Read Article Now Book Mark Article
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.
The outlook of HE depends on the management of 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.
Treating liver problems may prevent HE. Avoiding alcohol and intravenous drugs can prevent many liver disorders.
Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 144.
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.
Woreta T, Mezina A. Management of hepatic encephalopathy. In: Cameron AM, Cameron JL, eds. Current Surgical Therapy. 13th ed. Philadelphia, PA: Elsevier; 2020:428-431.
- Cirrhosis(Alt. Medicine)
- Alzheimer disease(Alt. Medicine)
- Viral hepatitis(Alt. Medicine)
- Brain tumors - primary(In-Depth)
- Parkinson disease(In-Depth)
- Sickle cell disease(In-Depth)
- Atherosclerosis(Alt. Medicine)
- Weight control and diet(In-Depth)
- Dementia(Alt. Medicine)
Review Date: 7/1/2021
Reviewed By: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.