Why liver damage could be bad news for the brain too

Liver is an important organ that filters and detoxifies the blood. But when it becomes dysfunctional, leading to toxins building up in the body, it can take an immediate toll on the brain. This condition is called hepatic encephalopathy (HE).

Dr Swati Raju, Consultant – Hepatology & Liver Transplant Physician, Fortis Hospital Vadapalani, Chennai, explains, “Encephalopathy means decreased mentation (mental activity) or altered sensorium (senses) in the brain. When it is caused by liver failure, it is called hepatic encephalopathy. Due to advanced liver disease, toxins like ammonia accumulate in the blood, as it’s not filtered by the liver. This flows to the brain, affecting its function.”

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Dr Tushar Raut, Consultant Neurology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, says, normally the food we eat is partly digested and partly excreted through the stool. “The protein intake in the diet is broken down into amino acids but because the liver is not able to metabolise, there is an increase in ammonia levels in the blood. The blood supplied to the brain is filled with this toxin, making the sodium ion channels (responsible for enabling a range of co-ordinations like locomotion and cognition) in neurons defective, leading to cellular edema or brain swelling,” he says.

Hepatic encephalopathy symptoms

He says encephalopathy is a condition where the brain function slows down. “It causes confusion, memory issues, slower mobility, disorientation, reversal of the sleep-wake cycle with the person sleeping more during the day and staying up at night. Sometimes, they can easily slip into coma too,” he adds. The symptoms can begin to develop slowly over a week or two but, it may worsen suddenly and within two hours, the person can slip into a coma. 

They can appear intermittently or remain persistent. “In the initial stage, it can be controlled with some medications. But they can recur. When the disease progresses, you may not be able to control it even with medications, until the person opts for a liver transplant,” adds Dr Raju.

Hepatic encephalopathy diagnosis

A 2021 article ‘Cognitive Impairment After Resolution of Hepatic Encephalopathy: A Systematic Review and Meta-Analysis’, published in the journal Frontiers in Neuroscience states that up to 40 per cent of cirrhotic patients develop HE. Dr Raut says the disease is quite common and one in about three to four people with end stage liver disease usually develop it.

It is diagnosed by examining the medical history in detail, talking to the person and their family members. “The family may start noticing that the person is sleeping a little more than usual, and has a lower attention span. A detailed neurological examination can also be done, if required. Some blood tests can help check the ammonia level in the blood,” says Dr Raju.

Dr Raut recalls a case of a 50-year-old working professional with severe liver cirrhosis (scarring) due to alcohol overuse. “He was comatose, and his bilirubin was high. He was on a ventilator and also had a seizure. We did MRI and EEG, which helped diagnose HE. We gave him medicines to reduce the swelling and some anticonvulsant drugs,” he says. When he got better, he underwent a liver transplant. “Now his HE is completely resolved. He is conscious, talking and moving around,” he says.

Factors that can trigger HE

Dr Raju says, “As liver diseases worsen, people can develop HE. There are some factors that can trigger it too.” 

• Constipation
• Sleeping pills or sedatives
• Painkillers
• Excess protein intake in diet
• Diuretics or water pills (help the body rid of salt and water) which helps in treating liver diseases. 

Measures to help prevent HE

Experts say it is important to treat the cause of liver disease to prevent further damage. “The basic reason for cirrhosis and liver failure must be controlled. It could be alcohol intake or non-alcoholic reasons such as obesity, uncontrolled sugar levels, thyroid or viral infections,” she says.

Once a person develops severe liver diseases, further complications need to be controlled. She says, “If the person is bleeding internally, vomiting blood, passing black-coloured stool or if fluid is building up in the abdomen, we prescribe diuretics. If there is a bleed, we do an endoscopy because the chance of HE is even higher as the blood stays in the gut. So, we try to prevent these complications.”

Dr Raut adds, “If one has hepatitis B or C, appropriate antiviral treatment can help prevent it from progressing into liver failure.” 

• Timely diagnosis of the liver disease
• Timely intake of medicines as per doctor’s advice
• Following a low protein diet
• Alcohol abstinence
• Regular follow-ups with the doctor

Takeaways

• People with end stage liver disease are more prone to developing HE.
• HE is caused by toxins built up in the blood, due to liver disease.
• The symptoms include confusion, reversal of sleep cycle, drowsiness, forgetfulness, inability to pay attention and delirium. The person may slip into a coma as well.
• Certain factors like constipation, diuretics overdose, sleeping pills can trigger HE in people with advanced liver disease.
• The key is to maintain proper liver health and reverse the condition before it’s too late.