One article to master: Clinical manifestations of hepatic encephalopathy | Clinical essentials

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Hepatic encephalopathy (HE) refers to a large group of syndromes in which neurological and neuropsychiatric abnormalities appear on the basis of liver disease.

In most cases, since the initial symptoms of HE are mild, it is difficult to determine the exact time of its onset.

HE is associated with poor prognosis.
Some studies have shown that once HE occurs in patients with liver disease, the mortality rate increases by more than 50% in the first year alone.

HE is a continuous manifestation from normal cognitive function, complete consciousness to coma, and can produce a wide range of neurological, mental, and musculoskeletal symptoms.

Many patients with only mild or early encephalopathy only report disturbances in the sleep-wake cycle.

1.
Neuropsychological testing In seemingly asymptomatic patients, clinical diagnostic scores can be used to reveal minor changes in the patient's mental state.

These neuropsychological tests include assessing the patient's attention, working memory, psychomotor speed, and visuospatial ability (Table 1).

Table 1 Commonly used clinical neuropsychological/physiological test methods and notes 2.
Clinical manifestations of HE 1.
Neuropsychiatric symptoms As the progress of HE, patients usually have personality changes, such as apathy, irritability, and disinhibition (referring to The state in which the internal restraint mechanism of individual behavior is lifted).

In many cases, patients will not report these symptoms themselves, but their family or friends may be aware of them.

Eventually, if not treated, these psychological symptoms will transform into cognitive impairment, including but not limited to disorientation, memory impairment, slurred speech, confusion and even coma.

Recently, the International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) used disorientation or flapping tremor as an initial indicator of dominant HE.

2.
Patients with musculoskeletal symptoms also show musculoskeletal symptoms, which are secondary symptoms of abnormalities in the motor system.

Like neuropsychiatric symptoms, the appearance of neuromuscular symptoms is based on the severity of HE.

Patients with the least impact on physical ability may experience handwriting or ataxia.

3.
Fluttering tremor The typical manifestation that can be observed in early to mid-stage patients is asterixis, which mainly refers to the inability to actively maintain position or posture.

It is currently defined as when the patient’s wrist is lifted flat and bent toward the back, it sometimes flaps like a bird’s wings.

The classic method of elicitation is to raise both arms flat, and when the fingers are separated, the palm of the hand appears flexion and extension.

This pathological posture involves a series of rapid, unconscious flexion and extension movements of the wrist, formerly known as "hepatic tremor.
"
Other parts that can induce hepatic tremor include tongue extension, dorsiflexion of the feet, clenched fists, and closed eyes.

In addition to HE, flapping tremor can also be seen in renal failure, congestive heart failure, respiratory failure, frontal lobe tumors, and hypokalemic encephalopathy.

4.
Extrapyramidal syndrome In the most severe cases, the musculoskeletal changes induced by HE can lead to hyperreflexia, clonus, and rigidity.

In the case of persistent HE, symptoms of Parkinson's disease related to liver cirrhosis may appear, leading to extrapyramidal reactions, including dull face, slow movement, and muscle tremor.

Different from other manifestations of HE, the symptoms of Parkinson's syndrome have an obvious feature, that is, it is irreversible.

3.
The classification of HE At present, the West-Haven HE classification standard is the most widely used at home and abroad, which divides HE into 0-4 levels.

The main defect of this classification standard is that it is highly subjective for the judgment of level 0 (maybe MHE) and level 1.

MHE is that there is no detectable abnormal changes in personality or behavior, and the nervous system signs are normal, but the neuropsychological test is abnormal.

In the clinical manifestations of grade 1 HE, signs of euphoria or depression or shortened attention time are difficult to identify.
Only careful relatives who understand the patient’s personality can insight into the patient’s mild cognitive dysfunction.
The repetitive and repetitive changes in clinical practice and multicenter studies Poor operability.

Therefore, my country's guidelines have been revised on the basis of the West-Haven classification (Tables 2 and 3).

Table 2 Revised HE Classification Standard Table 3 Revised HE Classification and Symptoms and Signs References: [1] Peter Dellatore, Maggie Cheung, Noah Y.
Mahpour, et al.
Clinical Manifestations of Hepatic Encephalopathy[J].
Clin Liver Dis (2020).
https://doi.
org/10.
1016/j.
cld.
2020.
01.
010[2] Chinese Medical Association Hepatology Branch.
Guidelines for diagnosis and treatment of liver cirrhosis and hepatic encephalopathy[J].
Chinese Journal of Hepatology.
2018,26 (10): 721-736.
[3] Wang Fusheng, et al.
Schiff Hepatology (11th edition) [M].
Peking University Medical Press.
2015.