Clinical features

HE can be described as a continuum ranging from subtle psychomotor changes with intact consciousness to coma arising in patients with impaired liver function or portosystemic shunting (1,2). Neurological features of HE include:

• psychomotor slowing - is the first neuropsychological feature seen in HE patients.
  • this can only be detected on psychometric testing
• subtle cognitive impairment and difficulties in concentration –
• trivial lack of awareness
• euphoria or anxiety
• impairment of addition or subtraction (for example, serial 7s test)
• reversal of the sleep-wake cycle – early sign in some patients
• affective changes including depression and occasionally personality changes are observed (such as irritability and inappropriate behaviour)
• agitation and aggression can progress to acute confusion leading to progressive stupor and coma.
• asterixis ( “liver flap”)
  • an arrhythmic negative myoclonus and loss of postural tone with a frequency of 3-5 Hz
  • may be bilateral or asymmetric
  • normally seen in the hands but can affect other parts of the body.
  • may be more easily felt than seen

The condition improves in association with improvement in liver function.

References:

1. Ellul MA, Gholkar SA, Cross TJ.Hepatic encephalopathy due to liver cirrhosis. BMJ. 2015;351:h4187.
2. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug;60(2):715-35.