Hepatic Encephalopathy

Juan Córdoba, M.D.; Beatriz Mínguez, M.D.

Disclosures

Semin Liver Dis. 2008;28(1):70-80. 

In This Article

Abstract and Introduction

Hepatic encephalopathy is a severe complication of cirrhosis that is related to the effects of ammonia. Analysis of interorgan ammonia trafficking has identified an important role of skeletal muscle in ammonia removal and has highlighted the importance of the nutritional status. Ammonia causes neurotransmitter abnormalities and induces injury to astrocytes that is partially mediated by oxidative stress. These disturbances lead to astrocyte swelling and brain edema, which appear to be involved in the pathogenesis of neurological manifestations. Inflammatory mediators worsen brain disturbances. New methods for assessing hepatic encephalopathy include clinical scales, neuropsychological tests, imaging of portal-systemic circulation, and magnetic resonance of the brain. Reappraisal of current therapy indicates the need for performing placebo-controlled trials and the lack of evidence for administering diets with restricted protein content. Liver transplant should be considered in selected patients with hepatic encephalopathy. Future prospects include new drugs that decrease plasma ammonia, measures to reduce brain edema, and liver-support devices.

Hepatic encephalopathy (HE) is a frequent and serious complication of cirrhosis that carries prognostic implications. In recent years, we have witnessed important achievements in the management of the complications of cirrhosis, which are reviewed in this issue of Seminars in Liver Disease. This progress has been the consequence of a better understanding of their patho-physiology. Several investigators have tried to match these achievements in the field of HE. The research has been focused on a reanalysis of ammonia metabolism, applying developments of neuroscience in the study of its pathogenesis, better delineation of the clinical presentation, new diagnostic tools, and a critical reappraisal of available therapies, including nutrition and liver transplant. In this article we will review the most significant progress in each of these aspects.

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