Hepatic Encephalopathy Is a Treatable Cause of Memory Loss

Hepatic encephalopathy (HE) (also called portosystemic encephalopathy) is a condition where liver disease affects brain functioning. HE often occurs in people who have diagnoses such as hepatitis or liver cirrhosis. It can also develop as a result of liver cancer. As liver disease progresses, the toxins that a healthy liver should be removing from the blood instead travel to the brain and impact its ability to function normally, think clearly, and remember information. Fortunately, this cause of memory loss is treatable.

Major Symptoms

HE can affect both cognitive and physical abilities. If you have liver disease, you should ask a family member or friend to help you watch for this group of symptoms and report them to your healthcare provider right away for prompt evaluation and treatment.

Symptoms range from barely detectable mental changes to unresponsiveness. They include:

• Confusion
• Memory loss
• Difficulty focusing or maintaining attention
• Disorientation to time, location or date
• Personality changes
• Slower reaction times, both physically and mentally
• Difficult or socially inappropriate behavior
• Inability to do basic math problems
• Breath that has a sweet odor
• Shaking and jerking of the arms or legs
• Flapping up and down of arms when holding them straight out
• Slurring of speech
• Decreased alertness

Stages of Hepatic Encephalopathy

HE can be classified into different stages—also called grades—progressing from minimal to coma. The West Haven Grading System breaks down the stages of HE as follows.

Grade 0: Minimal HE

Minimal HE may result in subtle, small changes in your ability to think clearly, problem-solve, and remember information. Possible signs can include more difficulty accomplishing tasks at your work or driving infractions due to slower reaction times or decreased coordination. Minimal HE can sometimes escape detection unless a healthcare provider screens for it through cognitive testing.

Grade 1: Mild HE

Mild HE may cause some personality or mood changes and a decreased ability to concentrate on a task. Sometimes, problems with sleeping develop at this stage.

Grade 2: Moderate HE

Challenging or inappropriate behavior may develop in moderate HE. Your memory may become worse, as may your ability to perform math calculations. Writing may be more difficult because your hands may become shaky or jerky.

Grade 3: Severe HE

Severe HE may affect orientation. For example, you may be unsure as to what day it is or where you are. Your behavior may become more socially inappropriate and you may feel very sleepy or anxious. Mental and physical ability continue to decline in HE. 

Grade 4: Coma

In this stage, you will lose consciousness and become comatose (unresponsive). 

How Do I Know If I Have HE?

If you're having some of the symptoms described above but don't have problems with your liver, it's likely that your symptoms are triggered by a different cause of forgetfulness. Mental ability changes can be caused by dozens of conditions, some of which are reversible (such as delirium) and others that are progressive (such as Alzheimer's disease).

If you do have a liver condition such as hepatitis or cirrhosis, it is more likely that HE is the cause of your symptoms. Either way, you should contact your healthcare provider right away if you notice mental ability changes because several causes of memory loss have better outcomes if they're caught and treated early.

Diagnosis and Causes

Because HE may go undiagnosed until the later stages, it's difficult to gather accurate data on HE prevalence. Studies suggest that between 30 to 70 percent of people with liver cirrhosis develop HE.

HE is generally diagnosed by ruling out other conditions. If symptoms are due to HE, they will often begin to improve as soon as within 72 hours after treatment has begun. Therefore, an improvement after treatment has been started (or lack thereof) is sometimes used to confirm or rule out HE.

Some of the tests that may be conducted to evaluate if HE is present include complete blood count tests, ammonia level testing, liver functioning tests, an EEG, and imaging tests, such as an MRI or CT scan.

While HE occurs in people with liver problems, there is often a specific trigger that causes HE to develop. These triggers may include infections, certain medications such as diuretics (medications that cause you to urinate more), dehydration, constipation, drinking too much alcohol, recent surgery, and gastrointestinal (GI) bleeding.

Treatment and Prognosis

Treatment varies depending on if the specific cause of the HE has been identified. Treatment may include antibiotics, discontinuing certain medications that may be causing some of the problems, treating with medications such as lactulose or polyethylene glycol, addressing bleeding problems, reducing ammonia levels, and treating kidney problems.

The prognosis of people with HE varies significantly. Some people with HE respond very well to treatment and their normal functioning returns. Others have severe or repeated bouts of HE and may end up hospitalized or in a life-threatening situation.

About three-quarters of people who have HE will improve if the specific cause of HE is identified and treated in its earlier stages. However, if HE is not treated early enough or doesn't respond to treatment, it can result in death.

Because of the success of early treatment, some research suggests that people with liver diseases should routinely be screened for HE through cognitive tests so that HE can be caught and treated before it progresses into the more advanced stages.