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Hepatic Encephalopathy in Patients with Cirrhosis

Marsha Y Morgan, FRCP, and Matthew Stubbs, BSc

Hepatic encephalopathy comprises a spectrum of neuropsychiatric abnormalities that range from clinically indiscernible changes in cognition, to clinically obvious changes in intellect, behavior, motor function, and consciousness. It impacts detrimentally on the lives of all those affected and on their survival. Ammonia plays a key role in the genesis of the syndrome; it is produced in excess in the gut and impinges on the brain where it induces astrocyte swelling, which ultimately impacts on neuronal function. The diagnosis of the syndrome remains problematic because the clinical signs, even when present, are often subtle and easily missed. There is no diagnostic gold standard; a combination of clinical examination, psychometric testing, and electroencephalography is recommended. Newer diagnostic approaches need further validation. Treatment is directed at reducing the circulating ammonia load, primarily through the use of non-absorbable disaccharides/non-absorbable antibiotics, and is generally effective. Newer treatment approaches, based on recent insights into the pathogenesis of the syndrome, await further evaluation.

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