Why does the brain suffer from liver disease?
The liver works as a filter: it converts ammonia produced in the intestines during the breakdown of protein into harmless urea. With cirrhosis, there are few liver cells left, and the blood bypasses through dilated veins - portosystemic shunts. Ammonia and other toxins enter the general bloodstream and affect brain cells: signal transmission is disrupted, water is retained, and the brain swells slightly. That is why symptoms begin not with pain, but with changes in attention, sleep and behavior that others notice before the person himself.
- Type A - for acute liver damage, such as severe hepatitis
- Type B - with shunts between veins without cirrhosis
- Type C - the most common, against the background of cirrhosis
- Hidden (minimal) form - visible only by special tests
- Explicit form - noticeable disturbances in behavior and consciousness
What triggers an attack
An exacerbation almost always has a cause, and finding it is half the treatment. Most often, this is bleeding from varicose veins of the esophagus: blood in the intestines becomes a source of protein and ammonia. Other common triggers are infection, including inflammation of ascitic fluid, constipation, dehydration due to vomiting or excess diuretics, and potassium and sodium imbalance. Sleeping pills and sedatives play their role: with a diseased liver, they are excreted slowly and increase lethargy.
- Bleeding from the veins of the esophagus or stomach
- Infection, including spontaneous bacterial peritonitis
- Constipation and stagnation of intestinal contents
- Diuretic overdose, dehydration
- Decreased potassium and sodium in the blood
- Alcohol, sleeping pills and sedatives
- A sharp transition to a very large amount of protein
Stages and symptoms
Doctors distinguish four stages according to the West Haven scale. In the first stage, a person becomes absent-minded, confuses day and night, gets irritated by little things, and writes and counts worse. In the second stage, drowsiness, slow speech, inappropriate actions and flapping tremor appear. On the third, the patient sleeps almost constantly, but he can still be woken up, he is disoriented. The fourth stage is coma. A hidden form is distinguished separately: there are almost no complaints, but the reaction speed is reduced, which is dangerous when driving a car.
- Confused sleep and wake patterns
- Absent-mindedness, forgetfulness, difficulty with counting
- Changing handwriting and drawing
- Slow slurred speech
- Flapping hand tremor
- Inappropriate behavior, euphoria or apathy
- Sweetish liver odor from the mouth
How to make a diagnosis
Diagnosis is clinical: The doctor evaluates consciousness, speech, orientation, and tremors in a person with known liver disease. Blood ammonia helps confirm the mechanism, but a normal level does not remove the diagnosis, and a high level by itself does not make it. Be sure to exclude other causes of confusion: low sugar, stroke, infection, poisoning, alcohol withdrawal. To evaluate the liver, liver tests, bilirubin, albumin, coagulogram and ultrasound with examination of the veins are prescribed; if the picture is unclear, a brain tomography is prescribed.
- Examination, West Haven scale, flapping tremor test
- Blood ammonia
- Liver tests ALT and AST, bilirubin, albumin
- Coagulogram and prothrombin with INR
- Complete blood count, electrolytes, glucose, creatinine
- Ultrasound of the liver and gallbladder, portal vein assessment
- Psychometric tests to identify latent form
Treatment and prevention of recurrences
Treatment proceeds in two directions: remove the provoking factor and reduce the formation of ammonia in the intestines. The basis of therapy is lactulose, which acidifies the intestinal contents, binds ammonia and ensures regular bowel movements; the dose is selected so that there is soft stool two to three times a day. If the effect is insufficient or repeated frequently, a non-absorbable intestinal antibiotic is added. You cannot starve and completely remove protein: this worsens muscle condition and prognosis; nutrition should be sufficient, with an emphasis on vegetable and milk protein. All medications are prescribed by a doctor.
- Elimination of the cause: stopping bleeding, treating infection, correcting electrolytes
- Lactulose orally or in enemas with dose selection based on stool
- Non-absorbable intestinal antibiotics as prescribed by a doctor
- Refusal of alcohol, sleeping pills and sedatives without consent
- Adequate nutrition with frequent meals and snacks at night
- Treatment of underlying liver disease and prevention of bleeding
- Discussion of liver transplantation for recurrent episodes