Understanding the impact of neurologic complications in patients with cirrhosis

Abstract

Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.

Status epilepticus as an initial manifestation of hepatic encephalopathy: A case report

“…Alcoholic cirrhosis is more likely to cause epilepsy[ 4 , 10 ]. There may be several reasons for this.…”

“…Although not all manifestations are reversible by LT[ 1 ], it remains the final option for HE. Some reports suggest that damage to the central nervous system is reversible when elevated blood ammonia concentration does not exceed 200-400 mg/dL[ 26 ], and continuous improvement in cognition has been observed during the first year post-LT[ 10 ]. It has been also reported that 10% of patients present with seizures post-LT[ 9 ].…”

Minimal hepatic encephalopathy is associated to alterations in eye movements

“…Between 33 and 50% of patients with liver cirrhosis can develop minimal hepatic encephalopathy (MHE), the earliest form of hepatic encephalopathy (HE) 1 – 4 , which affects several million patients around the world 5 . MHE is characterized by mild cognitive impairment, alterations in attention 4 , 6 , 7 , psychomotor slowing and impaired motor coordination 7 , 8 , altered postural control 9 associated with increased risk of falls 10 , and impaired fitness to drive 11 , 12 .…”