Complications of Portal Hypertension: Hepatic Encephalopathy
Complications of Portal Hypertension: Hepatic Encephalopathy
Hepatic encephalopathy (HE) is a potentially reversible neuropsychiatric complication in a patient with acute or chronic liver disease or other causes of portosystemic shunts. HE may be manifested by alteration of intellect, impaired cognition, changes in personality, or a limited attention span. Encephalopathy in patients with cirrhosis carries a poor prognosis, with up to 50% 1-year mortality.
HE may be minimal, intermittent, or persistent. Episodic overt encephalopathy most frequently follows an acute precipitating event such as sedation, gastrointestinal bleeding, infection, placement of a transvenous intrahepatic portosystemic shunt, or sudden metabolic changes such as alkalosis or azotemia. Persisting encephalopathy causes continuous neuropsychiatric disturbance, the manifestations of which depend on the severity of the encephalopathy. An early clinical manifestation of encephalopathy is day and night sleep reversal, where the patient does not sleep well at night but easily sleeps throughout the day.
The 3 major classifications of HE are shown in Table 1.
Table 1. Classification of HE
Data from Ferenci P, et al.
The West Haven scale is the most common tool used to classify overt encephalopathy and depends on the severity of clinical manifestations such as confusion, asterixis, and ability or inability to arouse the patient. Stage 1 in patients with cirrhosis is marked by changes in personality, reversal of day-night sleeping patterns, agitation, and excitation with fulminant hepatic failure. Stage 2 includes asterixis, drowsiness, and inappropriate behavior. A patient in stage 3 is poorly arousable and readily falls back to sleep when not stimulated. Stage 4 is marked by a flaccid, nonarousable patient with absent responses to painful stimuli (Table 2).
Table 2. Stages of Overt Hepatic Encephalopathy
Data from Atterbury CE, et al.
Minimal HE (MHE) affects 40%-80% of patients with cirrhosis and cannot be identified during clinical examination. MHE affects activities of daily living through a reduced attention span and alteration of cognition and interpersonal interactions. It manifests as slowed reaction times while driving an automobile or during the playing of games. Patients identified with MHE are more likely to progress to overt encephalopathy.
What Is Hepatic Encephalopathy?
Hepatic encephalopathy (HE) is a potentially reversible neuropsychiatric complication in a patient with acute or chronic liver disease or other causes of portosystemic shunts. HE may be manifested by alteration of intellect, impaired cognition, changes in personality, or a limited attention span. Encephalopathy in patients with cirrhosis carries a poor prognosis, with up to 50% 1-year mortality.
HE may be minimal, intermittent, or persistent. Episodic overt encephalopathy most frequently follows an acute precipitating event such as sedation, gastrointestinal bleeding, infection, placement of a transvenous intrahepatic portosystemic shunt, or sudden metabolic changes such as alkalosis or azotemia. Persisting encephalopathy causes continuous neuropsychiatric disturbance, the manifestations of which depend on the severity of the encephalopathy. An early clinical manifestation of encephalopathy is day and night sleep reversal, where the patient does not sleep well at night but easily sleeps throughout the day.
Classification of Hepatic Encephalopathy
The 3 major classifications of HE are shown in Table 1.
Table 1. Classification of HE
| Type | Associated With |
| Type A | Acute liver failure |
| Type B | Portosystemic shunts |
| Type C | Chronic liver disease |
The West Haven scale is the most common tool used to classify overt encephalopathy and depends on the severity of clinical manifestations such as confusion, asterixis, and ability or inability to arouse the patient. Stage 1 in patients with cirrhosis is marked by changes in personality, reversal of day-night sleeping patterns, agitation, and excitation with fulminant hepatic failure. Stage 2 includes asterixis, drowsiness, and inappropriate behavior. A patient in stage 3 is poorly arousable and readily falls back to sleep when not stimulated. Stage 4 is marked by a flaccid, nonarousable patient with absent responses to painful stimuli (Table 2).
Table 2. Stages of Overt Hepatic Encephalopathy
| Stage | Arousal | Behavior | Findings |
| Stage 0 | Normal | Normal | None |
| Stage 1 | Mild lack of awareness | Poor attention span | Asterixis or tremor |
| Stage 2 | Lethargic | Disoriented | Asterixis |
| Stage 3 | Arousable | Marked disorientation | Hyperreflexia |
| Stage 4 | Coma | Coma | Decerebrate posturing |
Minimal Hepatic Encephalopathy
Minimal HE (MHE) affects 40%-80% of patients with cirrhosis and cannot be identified during clinical examination. MHE affects activities of daily living through a reduced attention span and alteration of cognition and interpersonal interactions. It manifests as slowed reaction times while driving an automobile or during the playing of games. Patients identified with MHE are more likely to progress to overt encephalopathy.