Hepatic encephalopathy history and symptoms: Difference between revisions

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Latest revision as of 15:36, 26 January 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

In patients with hepatic encephalopathy, symptoms may have an insidious onset and progression, or may begin suddenly and progress rapidly. The hallmark of hepatic encephalopathy is hyperammonemia. A positive history of hepatic failure is suggestive of hepatic encephalopathy. The most common symptoms of hepatic encephalopathy include inverted sleep-wake pattern (combination of restless nights and excessive daytime sleepiness), personality changes, altered level of consciousness, bilateral flapping hand tremors on arm extension (asterixis), confusion and irritability.

History and Symptoms

In patients with hepatic encephalopathy, symptoms may have an insidious onset and progression, or may begin suddenly and progress rapidly. The hallmark of hepatic encephalopathy is hyperammonemia leading to altered mental status.^[1] A positive history of hepatic failure is suggestive of hepatic encephalopathy. The most common symptoms of hepatic encephalopathy include inverted sleep-wake pattern (combination of restless nights and excessive daytime sleepiness)^[2], personality changes^[3], altered level of consciousness^[4], bilateral flapping hand tremors on arm extension (asterixis)^[5], confusion and irritability.^[6]

History

Patients with hepatic encephalopathy may have a positive history of:^[7]^[8]^[3]^[6]^[9]^[10]^[11]

Common symptoms

Common symptoms of hepatic encephalopathy include:

Personality changes
Altered level of consciousness
Bilateral flapping hand tremors on arm extension (asterixis)
Confusion
Irritability
Inverted sleep-wake pattern (combination of restless nights and excessive daytime sleepiness)

References

↑ Rimar D, Kruzel-Davila E, Dori G, Baron E, Bitterman H (2007). "Hyperammonemic coma--barking up the wrong tree". J Gen Intern Med. 22 (4): 549–52. doi:10.1007/s11606-007-0131-6. PMC 1829435. PMID 17372808.
↑ Montagnese S, Turco M, Amodio P (2015). "Hepatic encephalopathy and sleepiness: an interesting connection?". J Clin Exp Hepatol. 5 (Suppl 1): S49–53. doi:10.1016/j.jceh.2014.06.006. PMC 4442851. PMID 26041958.
↑ ^3.0 ^3.1 Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
↑ al-Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.
↑ Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.
↑ ^6.0 ^6.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.
↑ Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.
↑ Acharya SK (2015). "Management in acute liver failure". J Clin Exp Hepatol. 5 (Suppl 1): S104–15. doi:10.1016/j.jceh.2014.11.005. PMC 4442864. PMID 26041950.
↑ Jepsen P, Christensen J, Weissenborn K, Watson H, Vilstrup H (2016). "Epilepsy as a risk factor for hepatic encephalopathy in patients with cirrhosis: a cohort study". BMC Gastroenterol. 16 (1): 77. doi:10.1186/s12876-016-0487-3. PMC 4960784. PMID 27457247.
↑ Guevara M, Baccaro ME, Ríos J, Martín-Llahí M, Uriz J, Ruiz del Arbol L; et al. (2010). "Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration". Liver Int. 30 (8): 1137–42. doi:10.1111/j.1478-3231.2010.02293.x. PMID 20602681.
↑ Jepsen P, Watson H, Andersen PK, Vilstrup H (2015). "Diabetes as a risk factor for hepatic encephalopathy in cirrhosis patients". J Hepatol. 63 (5): 1133–8. doi:10.1016/j.jhep.2015.07.007. PMID 26206073.

[pmid17372808-1] Rimar D, Kruzel-Davila E, Dori G, Baron E, Bitterman H (2007). "Hyperammonemic coma--barking up the wrong tree". J Gen Intern Med. 22 (4): 549–52. doi:10.1007/s11606-007-0131-6. PMC 1829435. PMID 17372808.

[pmid26041958-2] Montagnese S, Turco M, Amodio P (2015). "Hepatic encephalopathy and sleepiness: an interesting connection?". J Clin Exp Hepatol. 5 (Suppl 1): S49–53. doi:10.1016/j.jceh.2014.06.006. PMC 4442851. PMID 26041958.

[pmid28533911-3] 3.0 ^3.1 Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.

[pmid4340155-4] -Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.

[pmid27089111-5] Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.

[pmid23006457-6] 6.0 ^6.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.

[pmid28680841-7] Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.

[pmid26041950-8] Acharya SK (2015). "Management in acute liver failure". J Clin Exp Hepatol. 5 (Suppl 1): S104–15. doi:10.1016/j.jceh.2014.11.005. PMC 4442864. PMID 26041950.

[pmid27457247-9] Jepsen P, Christensen J, Weissenborn K, Watson H, Vilstrup H (2016). "Epilepsy as a risk factor for hepatic encephalopathy in patients with cirrhosis: a cohort study". BMC Gastroenterol. 16 (1): 77. doi:10.1186/s12876-016-0487-3. PMC 4960784. PMID 27457247.

[pmid20602681-10] Guevara M, Baccaro ME, Ríos J, Martín-Llahí M, Uriz J, Ruiz del Arbol L; et al. (2010). "Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration". Liver Int. 30 (8): 1137–42. doi:10.1111/j.1478-3231.2010.02293.x. PMID 20602681.

[pmid26206073-11] Jepsen P, Watson H, Andersen PK, Vilstrup H (2015). "Diabetes as a risk factor for hepatic encephalopathy in cirrhosis patients". J Hepatol. 63 (5): 1133–8. doi:10.1016/j.jhep.2015.07.007. PMID 26206073.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Hepatic encephalopathy}}
-{{CMG}} {{AE}}
+{{CMG}};{{AE}}{{MMJ}}
-{{PleaseHelp}}
 ==Overview==
-One of the earliest manifestations of hepatic encephalopathy is "day-night reversal". In other words, affected individuals tend to sleep during the day and stay awake at night. Another early manifestation is impairment in spatial perception. This can be made apparent by noting the patient's poor ability to copy or draw various simple images, e.g cube, star, clock. This deficit can also be demonstrated by administering a test which has the patient connect a number of randomly placed dots on a sheet of paper (the "trail test" or "numbers connecting test").
+In patients with hepatic encephalopathy, [[symptoms]] may have an insidious onset and progression, or may begin suddenly and progress rapidly. The [[hallmark]] of hepatic encephalopathy is [[hyperammonemia]]. A positive history of [[hepatic failure]] is suggestive of hepatic encephalopathy. The most common [[symptoms]] of hepatic encephalopathy include inverted [[Sleep-wake schedule|sleep-wake pattern]] (combination of restless nights and [[excessive daytime sleepiness]]), [[personality changes]], [[Altered mental status|altered level of consciousness]], bilateral flapping hand [[tremors]] on [[arm]] [[extension]] ([[asterixis]]), [[confusion]] and [[irritability]].
 ==History and Symptoms==
-Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start.
+In patients with hepatic encephalopathy, [[symptoms]] may have an insidious onset and progression, or may begin suddenly and progress rapidly. The [[hallmark]] of hepatic encephalopathy is [[hyperammonemia]] leading to [[altered mental status]].<ref name="pmid17372808">{{cite journal| author=Rimar D, Kruzel-Davila E, Dori G, Baron E, Bitterman H| title=Hyperammonemic coma--barking up the wrong tree. | journal=J Gen Intern Med | year= 2007 | volume= 22 | issue= 4 | pages= 549-52 | pmid=17372808 | doi=10.1007/s11606-007-0131-6 | pmc=1829435 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17372808  }} </ref> A positive history of [[hepatic failure]] is suggestive of hepatic encephalopathy. The most common [[symptoms]] of hepatic encephalopathy include inverted [[Sleep-wake schedule|sleep-wake pattern]] (combination of restless nights and [[excessive daytime sleepiness]])<ref name="pmid26041958">{{cite journal| author=Montagnese S, Turco M, Amodio P| title=Hepatic encephalopathy and sleepiness: an interesting connection? | journal=J Clin Exp Hepatol | year= 2015 | volume= 5 | issue= Suppl 1 | pages= S49-53 | pmid=26041958 | doi=10.1016/j.jceh.2014.06.006 | pmc=4442851 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26041958  }} </ref>, [[personality changes]]<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref>, altered level of [[consciousness]]<ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref>, bilateral flapping hand [[tremors]] on [[arm]] [[extension]] ([[asterixis]])<ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>, [[confusion]] and [[irritability]].<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref>
-Symptoms may be mild at first. Family members or caregivers may notice that the patient has:
-*Breath with a musty or sweet odor
-*Change in sleep patterns
-*Changes in thinking
-*[[Confusion]] that is mild
-*[[Forgetfulness]]
-*Mental fogginess
-*Personality or mood changes
-*Poor concentration
-*Poor judgment
-*Worsening of handwriting or loss of other small hand movements
-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
-Patients with hepatic encephalopathy can become unconscious, unresponsive, and possibly enter a [[coma]]. Patients with hepatic encephalopathy are often not able to care for themselves because of these symptoms.
+===History===
+Patients with hepatic encephalopathy may have a positive history of:<ref name="pmid28680841">{{cite journal| author=Djiambou-Nganjeu H| title=Hepatic Encephalopathy in Liver Cirrhosis. | journal=J Transl Int Med | year= 2017 | volume= 5 | issue= 1 | pages= 64-67 | pmid=28680841 | doi=10.1515/jtim-2017-0013 | pmc=5490964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28680841  }} </ref><ref name="pmid26041950">{{cite journal| author=Acharya SK| title=Management in acute liver failure. | journal=J Clin Exp Hepatol | year= 2015 | volume= 5 | issue= Suppl 1 | pages= S104-15 | pmid=26041950 | doi=10.1016/j.jceh.2014.11.005 | pmc=4442864 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26041950  }} </ref><ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref><ref name="pmid27457247">{{cite journal| author=Jepsen P, Christensen J, Weissenborn K, Watson H, Vilstrup H| title=Epilepsy as a risk factor for hepatic encephalopathy in patients with cirrhosis: a cohort study. | journal=BMC Gastroenterol | year= 2016 | volume= 16 | issue= 1 | pages= 77 | pmid=27457247 | doi=10.1186/s12876-016-0487-3 | pmc=4960784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27457247  }} </ref><ref name="pmid20602681">{{cite journal| author=Guevara M, Baccaro ME, Ríos J, Martín-Llahí M, Uriz J, Ruiz del Arbol L et al.| title=Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration. | journal=Liver Int | year= 2010 | volume= 30 | issue= 8 | pages= 1137-42 | pmid=20602681 | doi=10.1111/j.1478-3231.2010.02293.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20602681  }} </ref><ref name="pmid26206073">{{cite journal| author=Jepsen P, Watson H, Andersen PK, Vilstrup H| title=Diabetes as a risk factor for hepatic encephalopathy in cirrhosis patients. | journal=J Hepatol | year= 2015 | volume= 63 | issue= 5 | pages= 1133-8 | pmid=26206073 | doi=10.1016/j.jhep.2015.07.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26206073  }} </ref>
+*[[Cirrhosis|Hepatic cirrhosis]]
+*[[Hepatic failure]]
+*[[Gastrointestinal bleeding]]
+*[[Portacaval shunt]]
-==Psychometric testing==
+*[[Epilepsy]]
-The [[Mini-Mental State Examination]] has been tested and scores do not correlate with encephalopathy<ref name="pmid23815160">{{cite journal| author=Koziarska D, Wunsch E, Milkiewicz M, Wójcicki M, Nowacki P, Milkiewicz P| title=Mini-Mental State Examination in patients with hepatic encephalopathy and liver cirrhosis: a prospective, quantified electroencephalography study. | journal=BMC Gastroenterol | year= 2013 | volume= 13 | issue=  | pages= 107 | pmid=23815160 | doi=10.1186/1471-230X-13-107 | pmc=3716589 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23815160  }} </ref>.
+*[[Diabetes mellitus]]
+*[[Hyponatremia|Hyponatraemia]]
+*[[Renal failure]]
+*[[Bilirubinemia|Hyperblilirubinemia]]
+*[[Hypokalemia]]
+*[[Sepsis]]
+===Common symptoms===
+Common [[symptoms]] of hepatic encephalopathy include:
+*[[Personality changes]]
+*Altered level of [[consciousness]]
+*[[Bilateral]] flapping hand [[tremors]] on [[arm]] [[extension]] ([[asterixis]])
+*[[Confusion]]
+*I[[irritability|rritability]]
+*Inverted [[Sleep-wake schedule|sleep-wake pattern]] (combination of restless nights and excessive [[daytime sleepiness]])
 ==References==
 {{Reflist|2}}
 [[Category:Disease]]
 [[Category:Gastroenterology]]
@@ Line 44: / Line 37: @@
 [[Category:Neurology]]
 [[Category:Emergency medicine]]
-{{WH}}
-{{WS}}