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Siam Al Mobarak 201160021 Hasitha Sewmi 201160036 Deborah Igiraneza 201160035 Akaash Samyan 201160027 Pasindu Sankalpa 201160028

60028 Winny Wullur 201160026 Hiruni Mendis 201160023 Balu P. Anil 201160029

Hepatic encephalopathy is a worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood. In the advanced stages it is called hepatic coma or coma hepaticum. It may ultimately lead to death. Hepatic encephalopathy is characterized by personality changes, intellectual impairment, and a depressed level of consciousness

The main etiological factor in HE seems to be the accumulation of neurotoxic substances in the systemic circulation When liver function is seriously impaired, these compounds bypass the liver, gain direct access to the circulation and, once they cross the blood-brain barrier, may accumulate in the central nervous system.

Damage to astrocytes characterized by cell swelling (acute liver failure) or Alzheimer Type II astrocytosis (chronic liver failure) can be readily reproduced by acute or chronic exposure of these cells in vitro to pathophysiologically relevant concentrations of ammonia.

There is evidence that toxins can impair neuronal function in HE through several distinct mechanisms, including depression of neuronal electric activity by occupation of brain neuroreceptors ; inhibition of ionic Pumps and inhibition of neuronal oxidative metabolism.

The mildest form of hepatic encephalopathy is difficult to detect clinically, but may be demonstrated on neuropsychological testing. It is experienced as forgetfulness, mild confusion, and irritability.

The first stage of hepatic encephalopathy is characterised by an inverted sleep-wake pattern (sleeping by day, being awake at night). The second stage is marked by lethargy and personality changes. The third stage is marked by worsened confusion. The fourth stage is marked by a progression to coma.

More severe symptoms may include:


Abnormal movements or shaking of hands or arms Agitation, excitement, or seizures (occur rarely) Disorientation Drowsiness or confusion Inappropriate behavior or severe personality changes Slurred speech Slowed or sluggish movement

Hepatic encephalopathy may become a medical emergency. Hospitalization is required. The first step is to identify and treat any factors that may have caused hepatic encephalopathy. Gastrointestinal bleeding must be stopped. The intestines must be emptied of blood. Infections, kidney failure, and electrolyte abnormalities (especially potassium) need to be treated. Life support may be necessary to help with breathing or blood circulation, particularly if the person is in a coma. The brain may swell, which can be life-threatening. Patients with severe, repeated cases of encephalopathy may be told to reduce protein in the diet to lower ammonia production. However, dietary counseling is important, because too little protein in the diet may cause malnutrition. Critically ill patients may need specially formulated intravenous or tube feedings.

The antibiotics neomycin and metronidazole were previously used as a treatment for hepatic encephalopathy.
Later studies showed that neomycin was indeed absorbed enterally, with resultant complications. Metronidazole, similarly, was abandoned because prolonged use could cause a peripheral neuropathy (nerve damage), and many experience gastrointestinal side effects. A safer and probably more effective antibiotic is rifaximin, a nonabsorbable antibiotic from the rifamycin class Due to more widespread experience, it is only used as a second-line treatment if lactulose is not effective or poorly tolerated. When added to lactulose, the combination of the two may be more effective than each component separately

Prevention

Treating liver disorders may prevent some cases of hepatic encephalopathy. Avoiding heavy drinking and intravenous drug use can prevent many liver disorders. If there are any nervous system symptoms in a person with known or suspected liver disease, call for immediate medical attention. Avoid foods which are high in proteins. Prevent gastro-intestinal bleeding. Treat infections vigorously - Even the less virulent coughs and colds can complicate the hepatic disease and lead to an encephalopathic state. Thus, treating them early would be advisable. Do not take medications which are not prescribed by a doctor and that are more than the recommended dosage.

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