Hepatic coma : liver disease the loss of brain function when a damaged liver doesn't remove toxins from the blood.

Hepatic coma or hepatic encephalopathy generally occurs in people with chronic liver disease, such as cirrhosis or hepatitis. Triggers include infection and dehydration.

1. HEPATIC COMA BY: Mahim Zaidi M.SC (h.sc) sem –iv , snggpg college

2. Content: HEPATIC COMA : OVERVIEW SYMPTOMS CAUSES TYPES DIAGNOSIS TREATMENT

3. LIVER DISEASE: HEPATIC COMA Hepatic coma, also known as hepatic encephalopathy (HE), is a serious neurological condition that occurs as a complication of liver dysfunction. It's typically associated with advanced liver disease, such as cirrhosis, although it can also occur in acute liver failure. Hepatic coma occurs when the liver is unable to properly detoxify harmful substances in the blood, leading to the accumulation of toxins, particularly ammonia, which affects brain function. Hepatic encephalopathy, also called portosystemic encephalopathy, happens when your liver isn’t filtering toxins as it should. These toxins build up in your blood and affect your brain, causing confusion, disorientation and other changes. Hepatic encephalopathy can get better with treatment, but it can be life-threatening without.

4. SYMPTOMS OF HEPATIC COMA: Hepatic encephalopathy can show up in a wide variety of ways. Not everyone will have every symptom. It can affect your: Mood and personality. Behavior and impulse control. Memory, concentration and thinking. Consciousness, lucidity and sleep patterns. Coordination and motor functions. Autonomy and ability to care for yourself.

5. Symptoms may occur suddenly or come on gradually, and they may be steady and lasting or come and go in episodes. They may get better or worse, depending on your overall health condition. Hepatic encephalopathy can be mild to severe, and symptoms may be barely noticeable to striking. Healthcare providers sometimes group symptoms by their severity as a way of grading, or staging, the disease. Grading system The West Haven Criteria is the most common grading system healthcare providers use for hepatic encephalopathy. It grades symptoms on a scale of 0 to 4. Stages 0 to 1 are sometimes called minimal hepatic encephalopathy (MHE) or covert HE. Symptoms in these stages may not be outwardly noticeable. Stages 2 to 4, also called overt hepatic encephalopathy, feature more obvious symptoms.

6. Symptoms by grade Possible symptoms by grade include: Grade 0 Subtle changes  in short-term memory, concentration and reaction time, only recognizable perhaps to you or those closest to you. They might show up on standard  neuropsychological tests . Grade 1 Mild  confusion  or forgetfulness. Mood swings, like euphoria or anxiety. Difficulties adding and subtracting. Difficulties with  fine motor skills , like writing. Sleeping during the day and waking at night.

7. Grade 2 Clear personality changes. Inappropriate or out-of-character behaviors. Lethargy  and  apathy . Disorientation in time (what day or year is it?). Slurred speech ( dysarthria ). Grade 3 Slow thinking and sluggish movements. Disorientation in space (Where am I?). Drowsiness and loss of general awareness. Severe confusion,  delirium  or  amnesia . Involuntary  twitching , tremors or  asterixis . Grade 4 Total loss of consciousness ( coma) .

8. CAUSES OF HEPATIC COMA Hepatic coma is primarily caused by liver dysfunction or failure. The liver plays a crucial role in filtering toxins from the blood, including ammonia, which is a byproduct of protein metabolism. When the liver is damaged or fails, toxins accumulate in the bloodstream and reach the brain, causing neurological symptoms. The blood your liver filters comes directly from your  digestive system , via your  portal vein   (portal circulation). This blood carries waste products left over from the digestive process, including ammonia and others. Your liver filters them out before sending the blood back out to your body (systemic circulation). If it doesn’t, they  build up in your blood   and eventually damage your brain tissues. 

9. TYPES OF HEPATIC COMA: Healthcare providers define different types of hepatic encephalopathy based on the original cause. Type A : It is caused by acute liver failure . This is a sudden loss of liver function due to a sudden, severe liver injury.  Viral infections , autoimmune liver disease and  acetaminophen poisoning  are common causes.  Cerebral edema , swelling in your brain, is a frequent side effect that may contribute to the effects of hepatic encephalopathy. Acute liver failure is an emergency and some cases may require a liver transplant. Type B: It is caused by a portosystemic shunt . A shunt is when blood flow bypasses its normal route through a new, abnormal passageway. A portosystemic shunt is when your portal circulation bypasses your liver on its way to your systemic circulation. Your body may create a shunt if there's a blockage in the normal pathway.

10. Type C: It is caused by chronic liver failure . Chronic liver failure is the gradual decline of liver function from chronic liver disease. It’s not reversible. Chronic  hepatitis C , chronic  alcohol use disorder  and  metabolic dysfunction-associated steatotic liver disease (MASLD)  are common causes. At this stage, extensive scarring in your liver ( cirrhosis ) ma y prevent it from working right. Triggering events Chronic liver disease works slowly, and you can live with it for a long time before it really begins to affect you. Your body compensates for it until it can’t, which is when liver failure sets in. Healthcare providers have noticed that it’s often a secondary health problem or stress factor that tips the scales enough to trigger hepatic encephalopathy in people with chronic liver disease. These triggers might include: Acute gastrointestinal bleeding . Acute kidney failure . Infection. Surgery. Constipation . Dehydration . Electrolyte imbalance . Taking the wrong medication. An alcohol binge.

11. HEPATIC COMA : DIAGNOSIS Several tests are used to diagnose hepatic encephalopathy. Blood tests A  complete blood count  checks your  red blood cells ,  white blood cells , and platelets. A low red blood cell count indicates  blood loss  and a lack of oxygen. Blood tests may also be used to check your blood levels of  sodium ,  potassium , and ammonia. Having too much of these substances is a sign of impaired liver function. Imaging tests An imaging test, such as a  CT scan  or  MRI , can check for  bleeding in your head  or  abnormalities in your brain . Liver function tests Liver function tests  check for raised  enzyme  levels. An increase in enzymes indicates stress on your liver or liver damage. Tell your doctor if you have kidney disease or liver disease. The symptoms you’re experiencing along with your medical history can sometimes be enough to diagnose hepatic encephalopathy.

12. TREATMENT OF HEPATIC COMA : Treatment for hepatic encephalopathy includes: Managing any urgent conditions that may have triggered it. Treating the underlying condition causing it (liver disease or shunt). Reducing the levels of toxins circulating in your blood. Treatment for the first two will vary, depending on the nature of the conditions affecting you. For liver failure, whether acute or chronic, there’s often no direct treatment. Healthcare providers try to reduce any stress factors affecting your liver and offer supportive care to address symptoms and complications

13. Reducing neurotoxins in your blood Healthcare providers target the neurotoxins in your blood at their source, which is in your gut. As many of these toxins are byproducts of certain  bacteria in your gut , providers may prescribe  antibiotics  to reduce the number of these bacteria. They combine these with an osmotic  laxative  to speed up the passage of food waste through your gut and reduce how much it can absorb into your bloodstream. Medications The most common medications healthcare providers prescribe are: Rifaximin .   This antibiotic is nonabsorbable by your intestines.  Neomycin  is an alternative. Lactulose .   This synthetic laxative draws water into your bowel. MiraLAX® is an alternative. Supplemental medications include: Branched-chain  amino acids . Branched-chain amino acid supplements can help build muscle and clear ammonia from your blood through your muscle tissue. Probiotics . Probiotics can encourage the more helpful types of gut bacteria to compete with the less helpful types that produce neurotoxins.

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