Hepatic Encephalopathy—a Hidden Danger

by David Cox RN BSN

• Liver cirrhosis is an increasingly common malady. Hepatic encephalopathy (H.E.) is a serious and common side effect of liver cirrhosis

• H.E. is often poorly understood by patients and their caregivers

• People with H.E. are at risk for harming themselves and others. H.E. is treatable, but requires increased vigilance by caregivers to maintain patient and caregiver safety

I once worked as a bedside nurse in a solid organ transplant unit of a major medical facility. Our unit handled patients being considered for or having received heart or lung transplants. We also had an abdominal transplant unit located just around the corner from our unit. Nursing staff for both units sometimes floated back and forth between the two, which made sense because all solid organ transplant patients have many things in common. But our staff’s focus was on organ failure above the diaphragm.

Although this hospital was not antiquated by any means, it became inadequate for the increased demand our organization was experiencing. So plans were in the works for building an entirely new facility. As the build-out progressed, we were informed that the patient mix on our unit was going to be changed. In the new hospital, the heart transplant candidates and recipients were going to be on the cardiovascular unit, and the rest would be on a unit that combined lung transplant patients with abdominal transplant patients, including people with liver failure. We didn’t know much about the liver folks except that they were sometimes messy—as in Code Brown. But this is the way things were going in our workplace, so the nursing staff resolved to make the best of it. “Learn to love the liver”, we told ourselves. Little did we know what kind of excitement, and even a little danger, we would soon experience.

Learning to Love the Liver

After we moved into our new hospital, the most common patients on our new nursing unit had some kind of liver issue—they had liver failure, and either were being considered for transplant or other treatment or were post-transplant. Although some of the transplant candidates were there because of liver cancer, by far the most common patients had some kind of liver failure. Liver cirrhosis, a scarring of the liver tissue that renders the affected areas incapable of functioning, is the most common cause of liver failure. At this time, it’s estimated that 2.2 million Americans currently are suffering with liver cirrhosis. Recent trends point to an increased incidence of this serious illness due to increases in fatty liver disease. And liver cirrhosis commonly causes a problematic side effect, hepatic encephalopathy (H.E.).

What is H.E.?

 Basically, H.E. causes inflammation in the brain due to the accumulation of ammonia in the blood. Ammonia is a normal product of the body’s digestive metabolism. A healthy, normal liver breaks it down into harmless compounds, but the failing liver no longer can do so. Population studies show that about 40 percent of people with liver cirrhosis also have H.E. A diagnosis of H.E. is very concerning because it’s associated with falls, motor vehicle accidents, frequent hospitalizations, and decreased survival in general. H.E. symptoms can include disorientation, confusion, and agitation. As we worked with these liver failure patients, we started to hear stories from their caregivers about certain incidents that happened to these unfortunate people and their caregivers. These stories often involved the person with H.E. wandering away from home at any time during the day or night, resulting in frantic searches by their caregivers or calls from police that the person was found wandering around disoriented—sometimes unclothed--and, due to appearing intoxicated, had been taken to the local jail for their own safety.

Excitement on Our Nursing Unit

One day at work I got to experience some of this first-hand. We were admitting a fellow who had H.E. with significant confusion and disorientation. These folks often were direct admits to our unit or the ICU due to their well-known histories. He came in from out of town with his wife, but she had gone to talk to staff at our Admissions office and was not with him when he came into the hospital room. He sat down on the bed at first but, due to his confusion, started to become agitated. He got up and was walking around the room while talking nonsense. As his agitation increased, I got very concerned—not only for his safety, but for the three of us staffers in the room with him. This guy was around 40 years old, about 6’2”, weighed about 240 lb., and was built like a linebacker. I was pretty sure that, if he got worked up enough, he could take all three of us out. But fortunately, his wife then showed up and was able to calm him down, so we could start treatment for the H.E. and get him stabilized.

Immediate Treatment for H.E.

The immediate treatment goal for disoriented H.E. patients, once a blood test shows a high level of ammonia (or for patients whose history is well known) is to rid the bloodstream of ammonia. This is also a maintenance goal for folks with this malady, so that they can remain stable. The classic and time-tested treatment is to administer a syrup containing lactulose, a sweet, synthetic non-absorbable sugar commonly used as a laxative. The lactulose passes through the G.I. tract unabsorbed until it gets to the colon. There, by several mechanisms, it eliminates ammonia from the body by breaking some of it down into harmless compounds, and pulling water into the colon to help flush out more ammonia along with loose stools. It is commonly given orally but, in emergent situations where the patient is unable or unwilling to drink the sugary liquid, it can be given via nasogastric tube or directly into the colon via an enema. (I was VERY thankful that we didn’t have to try to give an enema to the guy mentioned above!)

Maintenance Treatment Options for H.E.

Lactulose syrup is commonly used as a maintenance treatment for H.E. It’s effective and affordable. The treatment goal is for the patient to pass two or three BMs per day. That way they can be assured of cleansing themselves of the unwanted bloodstream ammonia. But this presents management problems—passing two or three (or more) very loose stools every day, often accompanied by abdominal discomfort and gas, is a quality-of-life issue for many of these folks. Another treatment option, used instead of or along with lactulose syrup, is an antibiotic called rifaximin (Xifaxan). Although its mechanism of action in treating H.E. is not well understood, it works well for many patients and is much better tolerated than lactulose syrup. Unfortunately, it has not yet gone generic. For people without decent health insurance, rifaximin commonly costs over $2000 per month. Other treatments are being investigated but are not commonly available currently. The only cure for liver failure is liver transplant.

Nursing Considerations for Patients with H.E.

An important teaching point for patients with H.E. and their caregivers is for them to know what the effective medications for H.E. are, and to make sure they can obtain them or already have an adequate supply. Noncompliance with lactulose is common, and the probable results of that noncompliance need to be considered. In addition to that, the more I worked with patients with H.E., the more obvious it became that effective caregiving is essential to their well-being. Some of our hospitalized patients were newly diagnosed with H.E., but more of them had a flareup of this condition that was well-known to them, their caregivers, and our medical staff. But in both groups, there was often a lack of adequate understanding of H.E.—not just the causes, but also effective treatment and management options, along with the possible problems associated with inadequate patient management.

Our unit didn’t have any kind of teaching tool for H.E. In addition, a diligent search of the medical and nursing literature turned up nothing—astounding for a condition that’s fairly common and that has the management and safety concerns noted above. That was a great motivation for me to create a teaching tool that touched on all the important facets of H.E.—causes, treatment options, and caregiver considerations. Stealing a concept from the popular movie Top Gun, a key teaching point is that people with symptomatic H.E. need a wingman—someone who will, in essence, keep an eye on their loved one with H.E. at all times. Exploring how that might best work in each individual situation needs to be part of the teaching encounter.

The Bottom Line

Hepatic encephalopathy (H.E.) is a common and potentially dangerous side effect of liver cirrhosis. Effective treatments for the symptoms of H.E. exist, but are not without affordability and lifestyle-related challenges. Caregivers need an effective understanding of both treatment options and patient safety considerations. Teaching on all aspects of H.E., including patient safety and management, can make a huge difference in the lives of people with H.E. and their caregivers.

Assessed and Endorsed by the MedReport Medical Review Board