Complications of cirrhosis III. Hepatic encephalopathy

Hepatic encephalopathy (HE) is a major neuropsychiatric complication of cirrhosis. HE develops slowly in cirrhotic patients, starting with altered sleep patterns and eventually progressing through asterixis to stupor and coma. Precipitating factors are common and include an oral protein load, gastrointestinal bleeding and the use of sedatives. HE is common following transjugular intrahepatic portosystemic stent shunts (TIPS). Neuropathologically, HE in cirrhotic patients is characterized by astrocytic (rather than neuronal) changes known as Alzheimer type II astrocytosis and in altered expression of key astrocytic proteins. Magnetic resonance imaging in cirrhotic patients reveals bilateral signal hyperintensities particularly in globus pallidus on T1-weighted imaging, a phenomenon which may result from manganese deposition. Proton (1H) magnetic resonance spectroscopy shows increases in the glutamine resonance in brain, a finding which confirms previous biochemical studies and results no doubt from increased brain ammonia removal (glutamine synthesis). Additional evidence for increased brain ammonia uptake and removal in cirrhotic patients is provided by studies using positron emission tomography and 13NH3. Recent molecular biological studies demonstrate increased expression of genes coding for neurotransmitter-related proteins in chronic liver failure. Such genes include monoamine oxidase (MAO-A isoform), the peripheral-type benzodiazepine receptor and nitric oxide synthase (nNOS isoform). Activation of these systems has the potential to lead to alterations of monoamine and amino acid neurotransmitter function as well as modified cerebral perfusion in chronic liver failure. Prevention and treatment of HE in cirrhotic patients continues to rely on ammonia-lowering strategies which include assessment of dietary protein intake and the use of lactulose, neomycin, sodium benzoate and L-ornithine-aspartate. The benzodiazepine receptor antagonist flumazenil may be effective in certain cases. A more widespread use of central nervous system-acting drugs awaits a more complete understanding of the precise neurotransmitter systems involved in the pathogenesis of HE in chronic liver failure.