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:
1. HEPATIC COMA : OVERVIEW
2. SYMPTOMS
3. CAUSES
4. TYPES
5. DIAGNOSIS
6. 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) may
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.

14. THANK YOU