Hepatic Encephalopathy

Medically Reviewed by Minesh Khatri, MD on March 15, 2024
7 min read

You've had liver disease for a while, but now you notice something different about the way you act and feel. Maybe you forget things or get confused when someone's talking to you. Your friends may tell you that your speech sounds slurred or that you say things that aren't appropriate.

And it isn’t only changes in behavior. You might feel sluggish or find that you can't move your hands well anymore. Or your breath doesn't smell like it should.

What's going on? Is there a link to the liver problems you've been dealing with for years?

It could be. You may have hepatic encephalopathy (HE), a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease. It affects a lot of things, like your behavior, mood, speech, sleep, or the way you move.

Sometimes the symptoms are so mild that it's hard for anyone to notice. But whether you have obvious signs or just a few subtle changes, it's important to see your doctor. The right treatment can help keep your condition under control, but if you don't take care of yourself, your condition will continue to worsen.

Your liver has several big jobs to do. One key task is to clean your blood by getting rid of harmful chemicals that your body makes.

Hepatic encephalopathy starts when your liver gets damaged from liver failure, severe acute liver disease, or another disease you've had a long time, like chronic hepatitis, Reye's syndrome, or cirrhosis. Either way, your liver doesn't work right anymore, and toxins get into your bloodstream and travel to your brain. They build up there and cause the mental and physical symptoms of HE.

Several things can trigger an episode or make your condition worse. For example, you could be at risk for problems if you have a tube called a shunt placed in your liver. You might have this done to help reroute your blood flow to treat cirrhosis or another long-term disease. There's a chance that this procedure will allow toxins to bypass your liver and move to your brain.

Other things can set off hepatic encephalopathy, too. It might happen because you:

  • Have an infection
  • Get constipated
  • Don't get enough to drink
  • Bleed from your intestines, stomach, or esophagus
  • Take certain medicines like certain sleeping pills, pain relievers, or water pills
  • Have kidney problems
  • Go on an alcohol binge.
  • Have certain electrolyte problems such as low sodium or potassium

Risk factors for HE include:

  • Chronic hepatitis B
  • Chronic hepatitis C
  • Chronic excessive alcohol abuse
  • Cirrhosis
  • Autoimmune liver disease

There's a lot of variety in the way HE affects people. Not everyone has the same symptoms. For some folks, they may be very slight or come and go.

In some cases, the effects of hepatic encephalopathy start slowly and then get worse bit by bit. But sometimes they hit you hard all at once.

There are some mental signs to watch out for. For instance, you may:

  • Get confused
  • Forget things
  • Feel nervous or excited
  • Notice a sudden change in your personality or behavior
  • Speak or act inappropriately to others
  • Not feel interested in things
  • Get cranky

Of course, when it comes to changes in behavior, sometimes you're the last one to realize that something is off. So if you've got a long-term liver disease, ask your family and friends to be on the lookout for shifts in your personality. Tell them to be honest with you if they see your mood has changed or you're just not acting like your old self.

You may also notice some changes in your sleep patterns. You could feel sleepy during the day or stay up late at night.

Some physical changes can start creeping in, too. You may notice that:

  • Your breath smells sweet or musty.
  • It's hard to move or use your hands.
  • When you hold out your arms or hands, they shake or flap.
  • Your speech sounds slurred.
  • You feel slow or sluggish when you move your body.

It may be hard to notice hepatic encephalopathy at first. Your family or friends may see changes in your behavior or movement before you do.

If you have a liver disease or had one in the past, your doctor may ask you if anyone has told you about changes in your personality. They'll examine you for signs of the physical symptoms that go along with the brain disorder.

They may also give you a blood test to check for high levels of ammonia. That's a sign that your liver is not clearing it from your bloodstream the way it should. Too much of that toxin can build up in your brain and lead to HE symptoms.

If your doctor diagnoses you with hepatic encephalopathy, some things to ask them are:

  • What stage of the brain disorder do I have?
  • What treatments do you recommend?
  • Will my symptoms get better or go away?
  • Will I have to change my diet?
  • Will I still be able to work, take care of myself, and drive?

You've got a number of choices. A lot depends on your specific situation. For instance, your doctor will take into account things like:

  • What triggers your episodes
  • How severe a case you have
  • The types of symptoms you get
  • How serious your long-term liver disease is
  • How old you are and your overall health

Your doctor may suggest two types of drugs that reduce the toxins in your body:

Lactulose. This is a type of sugar that can make you have more bowel movements. This helps get rid of some toxins from your body, like ammonia, which can trigger HE. Your doctor or nurse will explain how to figure out the right amount. For example, you will need to adjust your dose until you are having 2 to 3 bowel movements a day.

Antibiotics. Drugs like neomycin (Neo-Fradin) and rifaximin (Rifagut, Xifaxan) may help. They curb bacteria that create toxins when they digest your food.

Your doctor may also ask you to take some other steps that can improve your symptoms:

Change your diet. If you eat a lot of meat, your body may make too much ammonia. Your doctor may ask you to cut back, but you still need to get enough protein from other sources. Try dairy and veggies. Also eat frequent small meals rather than three big ones a day.

Skip alcohol. Even a little bit can be risky for you because it damages your liver.

Treat infections. They can affect the way your liver works. You may need antibiotics to get rid of them.

Treat urinary blockages. If you can't pee normally, it can trigger your HE. Treatment for the infection or disease that's causing it can help.

Stop some medications. Certain medicines, such as sedatives or narcotics, may cause problems with your liver.

Treat constipation. You may need to eat less meat and more vegetables. This can help you have more regular bowel movements so you can flush toxins from your body.

The best thing you can do to keep your HE under control is stick with the treatment plan that your doctor suggests.

Since you already have a lot of medical stuff to do because of your long-term liver disease, it might seem like your new treatment is a big nuisance. But it's really important. Don't skip any doses of medicines, and make sure you follow your doctor's diet advice. Ask your friends and family to help you stay on track.

If you play by the rules, you'll get results. Your symptoms can improve and sometimes go away.

HE can be divided into stages according to how severe your symptoms are. If you're in an early stage, the right treatment can ease your symptoms.

HE is graded based on signs and symptoms:

Grade 1Mild. You may have slurred speech, trouble sleeping, or find it hard to concentrate.

Grade 2: Moderate. You may feel like you don't have much energy. Some personality changes and confusion may become more obvious, like acting odd or forgetting things.

Grade 3Severe. You may be extremely confused and not be able to speak coherently. You could also get extremely sleepy or pass out, though you'll wake up when someone tries to rouse you.

Grade 4: Coma. In this phase, you may pass out and not respond to pain or someone trying to wake you.

These grades may sound scary, but remember, HE can be treated if you act promptly. Work with your doctor closely and follow their instructions carefully.

Even though treatment can keep your HE from getting worse, there may be times you'll need to get some care at home to help you when your symptoms are acting up. A caregiver can help you with some daily tasks. For instance, they can:

  • Shop for food
  • Help you dress and wash
  • Watch to see if your symptoms get worse

You also need to reach out to family and friends to get emotional support. They know you best and can give you the backing you need while you manage your symptoms.

It helps to talk to people who know about liver disease and HE firsthand. They'll understand just what you're going through. The American Liver Foundation has information about how to find support groups in your area. It also has a lot of useful advice on a website that's all about the diagnosis and treatment of hepatic encephalopathy.