Mental Impairment and Encephalopathy

Mental impairment is a common event in advanced cirrhosis. In severe cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from confusion to coma and death. A combination of conditions associated with cirrhosis causes this serious complication.

  • Buildup in the blood of harmful intestinal toxins, particularly ammonia
  • An imbalance of amino acids that effect the central nervous system

Encephalopathy is often triggered by certain conditions, including the following:

  • Gastrointestinal bleeding
  • Constipation
  • Infection
  • Surgery
  • Dehydration
  • Narcotic and Sedative Drugs

Symptoms of Encephalopathy

Early symptoms of hepatic encephalopathy include sleep-wake reversal (wanting to sleep all day and stay up all night), forgetfulness, unresponsiveness, and trouble concentrating. Sudden changes in mental state, including agitation or confusion, may indicate an emergency condition.

Other symptoms include bad fruity-smelling breath and tremor. Late stage symptoms of encephalopathy are stupor and eventually coma.


Managing encephalopathy

The first step in managing encephalopathy (damage to the brain) is to treat any precipitating cause, if known, such as:

  • High ammonia levels
  • Bleeding
  • Low oxygen
  • Dehydration
  • Infection
  • Use of sedatives

Ammonia is the leading toxin in causing encephalopathy related to cirrhosis. Mild encephlopathy is managed by directing therapy toward eliminating ammonia in the intestine:

  • Lactulose (Cephulac, Chronulac, Constulose, Duphalac, Enulose) and lactitol, known as disaccharides, help lower blood ammonia levels by binding the toxins and allowing the bowels to flush the bound toxins out of the body. Simply having 2-3 bowel movements a day will not BIND the toxins. Lactulose must be titrated up or down for 2-3 bowel movements in 24 hours.  Too many bowel movements will cause dehydration and risk confusion and kidney failure.
  • Antibiotics, such as metronidazole, rifamycin, Xifaxin or neomycin, are effective in reducing levels of ammonia-producing bacterial in the intestine, although long-term use of these drugs can cause toxic side effects.
  • Adding non-ammonia producing bacteria to the intestine, including L. acidophilus and E. faecium, is showing promise as a safe and effective treatment.

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