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Nurse resource

Nurses are an essential member of the healthcare team looking after patients with advanced chronic liver disease. This site provides information on hepatic encephalopathy (HE), the signs and symptoms to look out for, diagnosis and management of HE. Together with some helpful hints and tips provided by nursing colleagues, this site hopes to provide useful information on recognising and managing HE.

HE explained

An introduction to hepatic encephalopathy

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What is HE?

Hepatic encephalopathy (HE) is a significant complication of advanced chronic liver disease.1

According to the UK General Practice Research Database (GPRD), the prevalence of advanced chronic liver disease in the UK almost doubled between 1992 and 2001 to 76.3 per 100,000 persons.2

HE is a significant complication of advanced chronic liver disease1 and occurs in up to 40% of patients3 or as many as 200,000 Europeans.

HE is a decompensation event associated with liver insufficiency and portosystemic shunting and impacts heavily on the prognosis of a patient with cirrhosis.4

Overt HE

can present as a wide spectrum of mental and motor disorders, leading to loss of independence, reduced levels of consciousness and disturbances in behaviour and psychomotor function.1

Minimal HE

can be present in the patient with liver disease who is "clinically normal" but in whom mild cognitive and psychomotor deficits can be detected with specialised testing (e.g. pencil and paper tests, computerised tests).1

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Signs and symptoms

HE symptoms can range from mild to severe and can vary from patient to patient. Symptoms can develop rapidly or slowly over a period of time. Patients with HE can have both physical symptoms and reduced mental function (Table 1).1
It is important to look out for these symptoms in your patients with advanced chronic liver disease.

Ongoing assessment of a patient's behaviour and mental status is important because of the fluctuating nature of HE. It is important to know how rapid an episode of HE can develop, and how symptoms can change from day-to-day or even from hour-to-hour.

Table 1. Symptoms of HE1

Apathy, irritability and disinhibition may be reported by the patient's relatives and friends
Changes in personality
Euphoria or anxiety
Alterations in consciousness and motor function
Muscular rigidity, slowness of speech, tremor
Asterixis
Disturbances in the sleep-wake cycle with excessive daytime sleepiness
Disorientation to time and space
Inappropriate behaviour
Confusional state with agitation or somnolence
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Grading of HE

HE is usually graded according to the West-Haven or Conn Score. This is a clinical scoring system used in the grading of overt HE (Fig. 1). As minimal HE is not evident clinically and requires specific testing (see later), it is not graded using this scoring system.5,6

Figure 1. West-Haven Grading of HE (Conn Score)5,6

Grade 0 Normal clinical examination. (This grading system does not account for minimal HE which would be classified as Grade 0 clinically but may be shown by impaired psychometric tests)
Grade 1 Mild lack of awareness; shortened attention span; impaired performance of addition / subtraction; mild asterixix (liver flap) or tremor
Grade 2 Lethargy; disorientation; inappropriate behaviour; obvious asterixis; slurred speench
Grade 3 Somnolence but responsive to stimuli; gross disorientation; bizarre behaviour; muscular rigidity and clonus; hyper-reflexia
Grade 4 Coma (unresponsive to verbal or noxious stimuli); decerebrate posturing

Nurses may find it useful to carry a plastic card with the West-Haven criteria in their pocket, when meeting HE patients.

Asterixis (the ' flapping tremor ')

is one of the most commonly observed neurological abnormalities in HE patients, but how is it identified?

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ANSWER

Asterixis usually affects both sides of the body and can be seen by asking the patient to hold their arms outstretched with the fingers separated or by hyper-extending the wrists with the forearms fixed. It is often seen in patients with grade 2 HE or higher and is a sign of ‘overt HE’.

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Factors which can cause HE - Precipitants

  • HE is thought to be caused by increasing levels of ammonia, which can reach the brain and result in significant neuronal dysfunction.7
  • Often, an episode of HE is caused by another factor. These are referred to as precipitants.1
  • Common precipitating factors for HE are outlined in Table 2.1
Approximately 50% of patients with episodic HE have an identifiable precipitant.4

Table 2. Precipitating Factors for HE1

Gastrointestinal bleeding
Infections
Dehydration
  • Fluid restriction
  • Diuretic overdose
  • Diarrhoea/vomiting
Electrolyte disorder
Constipation
Excess protein load
Surgery
Alcohol misuse
Unidentified

For more information on the pathogenesis of HE and its precipitating factors, visit Module 2: Pathophysiology & Diagnosis of HE

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Diagnosis

  • Nurses are likely to encounter patients with advanced chronic liver disease and HE either in their clinics or on the wards, and are therefore in a great position to identify any changes in the patient.
  • A number of techniques and tests are used to diagnose minimal HE, such as the pencil and paper test, critical flicker frequency or electroencephalogram.1

When a nurse meets a patient with HE for the first time, it is important to identify the patient's pre-existing knowledge of HE, and to inform them that HE can be reversed. The patient should be informed and educated about the nature of HE, how to detect upcoming episodes of HE, and how to prevent HE. Regular meetings with the patient are important when assessing HE in order to get to know the patient and to detect any changes in behaviour.

‘How I...’ diagnostic videos

do pencil and paper tests

A practical guide on how to administer and interpret commonly used pencil and paper tests of cognitive function

use and interpret an EEG

A practical guide on the interpretation of EEG results in the context of HE

perform and use an EEG

When to consider ordering an EEG for your patients, what to ask for, how to perform an EEG and interpret the resultss

make a diagnosis

A clinically focused series of 'tips' on the differential clinical diagnosis of HE

do pencil and paper tests

A practical guide on how to administer and interpret commonly used pencil and paper tests of cognitive function

use and interpret an EEG

A practical guide on the interpretation of EEG results in the context of HE

perform and use an EEG

When to consider ordering an EEG for your patients, what to ask for, how to perform an EEG and interpret the resultss

make a diagnosis

A clinically focused series of 'tips' on the differential clinical diagnosis of HE

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For more information on the diagnosis of HE, visit Module 3: Diagnosis of HE

Management of HE

  • Treatments for HE are available which improve patient outcomes (Fig. 2).1,8,9
  • The most important aspect of HE management is prompt recognition of symptoms and treatment of precipitating factors; many patients can be successfully managed with correction of the precipitating factor.1,10

Figure 2. Recommended Treatment Pathway for Symptomatic HE1

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HE, Hepatic encephalopathy; ICU, intensive care unit

Nurses should encourage the patient to take their medicine prescribed by the doctor, to eat a healthy high-protein diet and the reasons why, and be aware of their stool frequency. Patients on lactulose may benefit from using a stool chart to provide accurate information on frequency and consistency of bowel actions. This can help determine if the dose of lactulose needs to be changed.

Self-care may provide the patient with a feeling of independence. In addition, patients should be advised about the risks in daily life that are associated with HE, such as operating machinery or driving a car.

When patients have recovered from an episode of HE they may feel scared and confused. Patients sometimes cannot remember anything from an episode of HE grade 3−4. It is therefore advised that the nurse quietly explains to the patient what has happened during their episode and what triggered HE, as this often helps to reassure the patient.

Building trust between the nurse and the patient is also an important part of a patient's treatment.

Patients should be managed depending on the severity of HE

Minimal HE: Be aware of the nature of HE, and know about the different ways to detect minimal HE (such as the psychometric hepatic encephalopathy score [PHES], critical flicker frequency or electroencephalogram). Caregivers or family members should be interviewed to report any change(s) in the patient's behaviour. Advise patients against driving. Please check the local driving laws about your responsibility.

Grade 1: When managing a patient with grade 1 HE it is important to:

  1. show patience when listening to the patient
  2. be supportive and help the patient perform basic activities
  3. remind the patient about taking their medicine and perhaps make a treatment diary
  4. draw up a diet plan with the patient. If the patient suffers from nausea and poor appetite a feeding tube may be necessary
  5. advise patients against driving. Please check the local driving laws about your responsibility

Grade 2: When managing a patient with grade 2 HE it is important to:

  1. protect the patient from bizarre behaviour and stigma (they are often not able to themselves)
  2. provide practical assistance (such as helping the patient with their clothing, provide assistance to the toilet)
  3. promote rest, comfort, and a quiet atmosphere
  4. help maintain their circadian rhythm
  5. identify and provide safety needs such as supervising during smoking, prepare the bed for the patient by setting it to the low position, and raising the side rails and pad, if necessary. Feeding tubes are often not an option at this HE grade as patients are often too confused to cooperate on the placing of the tube.
  6. closely watch the patient, as they may attempt to get out of bed, may be very confused and unable to stand
  7. advise the patient and their family about the serious risk of driving and liaise with the general practitioner or social worker to provide the support the patients may need. Please check the local driving laws about your responsibility

Grade 3: When managing a patient with grade 3 HE it is important to:

  1. frequently assess and record the patient's level of consciousness
  2. monitor the patient's food and drink intake, output, and fluid and electrolyte balance
  3. maintain a safe environment as the level of HE increases
  4. closely watch the patient, as they may attempt to get out of bed, may be very confused and unable to stand
  5. have a nurse or another healthcare provider beside the patient all day to calm the patient and protect him/her from harming themselves
  6. assess nutrition needs. At this HE grade enteral feeding can be too hazardous as the patient cannot protect his/her airways. Parenteral nutrition through a central venous catheter is therefore preferred
  7. advise the patient and their family about not driving. Even after the patient recovers to their baseline state, this group of patients should not drive for about a year. Please check the local driving laws about your responsibility

Grade 4: When managing a patient with grade 4 HE it is important to:

  1. frequently assess the patient's respiratory status, including respiratory rate and oxygen level
  2. protect the airway of patient
  3. consider turning the patient, and to place them on a pressure preventing mattress. At this HE grade enteral feeding can be too hazardous as the patient cannot protect his/her airways. Parenteral nutrition through a central venous catheter is therefore preferred
  4. advise the patient and their family about not driving. Even after the patient recovers to their baseline state, this group of patients should not drive for about a year. Please check the local driving laws about your responsibility
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Patient perspectives

  • Many patients with advanced chronic liver disease feel stigmatised by their disease.11
  • HE interferes with patient’s functioning, social interaction and sense of well-being.12 Caregivers also report effects on their ability to work with a sense of entrapment and poor personal health.13

It is important to ensure that patients with HE do not feel stigmatised and that they receive the same level of care and treatment as other patients.

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Glossary

Apathy The feeling of not having much emotion or interest
Asterixis A motor disturbance marked by intermittent lapses of an assumed posture as a result of intermittency of sustained contraction of groups of muscles; called liver flap because of its occurrence in hepatic coma, but observed also in other conditions
Clonus Alternate involuntary muscular contraction and relaxation in rapid succession
Cognitive Relating to or involving conscious mental activities (such as thinking, understanding, learning, and remembering
Decerebrate posturing An abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain
Decompensation event The development of clinically evident complications of portal hypertension or liver insufficiency
Euphoria Feeling of great happiness and excitement
Hyper-reflexia Overactive or over-responsive reflexes, such as twitching or spastic tendencies, which are indicative of upper motor neuron disease as well as the lessening or loss of control ordinarily exerted by higher brain centers of lower neural pathways
Portosystemic shunting A bypass of the liver by the body's circulatory system
Lethargy A lack of energy or a lack of interest in doing things
Precipitating factor An element that causes or contributes to the occurrence of a disorder
Somnolence Drowsiness or sleepiness, particularly in excess
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References

  1. American Association for the Study of Liver Diseases; European Association for the Study of the Liver. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol 2014; 61 (3): 642−59.
  2. Fleming KM, Aithal GP, Solaymani-Dodaran M et al. Incidence and prevalence of cirrhosis in the United Kingdom, 1992−2001: a general population-based study. J Hepatol 2008; 49 (5): 732−8.
  3. Amodio P, Del Piccolo F, Petteno E, et al. Prevalence and prognostic value of quantified electroencephalogram (EEG) alterations in cirrhotic patients. J Hepatol 2001; 35: 37−45
  4. Morgan MY. Hepatic encephalopathy in patients with cirrhosis. In: Sherlock's Disease of the Liver and Biliary System, 12th Edition, Blackwell Publishing Ltd, 2011; Chapter 8: 121−151.
  5. Conn HO, Leevy CM, Vlahcevic ZR, et al. Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. Gastroenterology 1977; 72 (4, pt 1): 573−83.
  6. Ferenci P, Lockwood A, Mullen K, et al. Hepatic encephalopathy − definition, nomenclature, diagnosis, and quantification: Final report of the working party at the 11th World Congress of Gastroenterology, Vienna, 1998. Hepatology 2002; 35: 716−21.
  7. Jalan R & Hayes PC. Hepatic encephalopathy and ascites. Lancet. 1997; 350: 1309−15.
  8. Sharma BC, Sharma P, Agrawal A, et al. Secondary prophylaxis of hepatic encephalopathy: An open label randomised controlled trial of lactulose verses placebo. Gastroenterology 2009; 137: 885−91.
  9. Bass NM, Mullen KD, Sanyal A,et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med 2010; 362 (12): 1071−81.
  10. Al Sibae MR, McGuire BM. Current trends in the treatment of hepatic encephalopathy. Ther Clin Risk Manag 2009; 5 (3): 617−26.
  11. Vaughn-Sandler V, Sherman C, Aronsohn A, et al. Consequences of perceived stigma among patients with cirrhosis. Dig Dis Sci 2014; 59 (3): 681−6.
  12. Arguedas MR, DeLawrence TG, McGuire BM. Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis. Dig Dis Sci 2003; 48: 1622−6.
  13. Bajaj JS, Wade JB, Gibson DP, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol 2011; 106 (9): 1646−53.
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Faculty Members

Carola Eriksson
Södra Älvsborg Hospital Borås, Sweden
Carola Fagerström Specialistsjuksköterska, Magtarmmedicinska kliniken, Sweden
Karen Faber
Gastroenterology Department, Odense University Hospital, Denmark
Rikke Baltzer
Medicinsk Hepato-gastroentrologisk afdeling V, Denmark

Editorial Assistance

Content development was supported by Ian Morgan MSc, Kalpesh Patel BSc (Hons) MSc, Sarah Diffen BPharm (Hons) MPharmSc 4C Consultants International.

The development of these activities was
co-ordinated by 4C Consultants International

4C/NINR/0116a date of preparation January 2016