Hepatic Encephalopathy, Explained — Plus the Breakfast This Hepatologist Actually Recommends

For people living with cirrhosis, some of the most important warning signs don't show up on a lab test first. They show up as a missed word, a shaky signature, a mood that feels slightly off. Hepatic encephalopathy (HE) is a brain complication of liver disease that can look, in its earliest stages, like ordinary life, which is exactly why it's so often missed until it becomes an emergency.

We spoke with Elliot B. Tapper, M.D., associate professor in the Division of Gastroenterology and Hepatology at University of Michigan Health and academic chief of hepatology, about what's actually happening in the brain during HE, the early signs patients and caregivers tend to overlook, and the daily habits, including a specific breakfast recommendation from the American Liver Foundation's 30-Day Meal Plan, that can mean the difference between a manageable condition and a revolving door at the hospital.

Huevos Rancheros

Ingredients:

• 4 large eggs
• 4 whole grain or whole wheat tortillas
• 1 cup homemade or low-sodium canned refried beans (or use black beans)
• 1 cup salsa (choose a low-sodium or no-sugar-added variety)
• 1 avocado, sliced or mashed
• 1/2 cup reduced-fat shredded cheese (cheddar or Mexican blend)
• Salt free seasoning
• Optional toppings: plain Greek yogurt (instead of sour cream), sliced jalapeños, hot sauce

Directions:

1. Heat a large skillet over medium heat and warm the tortillas until they are soft and heated through. Keep them warm.
2. In a separate non-stick skillet, cook the eggs to your preference using a small amount of cooking spray instead of oil. Season with salt free seasoning
3. Spread a thin layer of refried beans (or mashed black beans) on each warm tortilla.
4. Top each tortilla with a cooked egg. Spoon salsa over the eggs and sprinkle with reduced-fat shredded cheese.
5. Top each serving with sliced avocado or a dollop of mashed avocado. Sprinkle with chopped cilantro and serve immediately.

What is HE, and why does liver disease affect the brain?

Elliot B. Tapper, M.D.: HE is a spectrum of the brain caused by toxins the liver can no longer filter. Most toxins come from the gut and, in cirrhosis, blood is rerouted around the liver, delivering the toxins to the brain. The brain is relatively defenseless to these toxins which cause lots of problems.

What are the early warning signs?

ET: The early signs look like ordinary life, which is why they're missed. Poor mood, difficulty with numbers or concentration, poor balance and poor sleep quality are some of the earliest signs. Personality changes: irritability, apathy or being oddly cheerful. A slight tremor or handwriting that gets sloppy. If someone who knows you says, "you're not yourself," or that you are acting “goofy,” take it seriously.

What triggers an episode, and what can patients do day to day?

ET: Most episodes have a trigger: dehydration, infection, bleeding in the gut, or constipation and missed lactulose doses are amongst the most common. Day to day: take lactulose reliably enough to have two to three soft bowel movements daily—don't stop it because you feel fine. Stay hydrated. Eat regularly, including protein, and be sure to have a snack before bed! A balanced breakfast after waking up is important too. I recommend ALF’s huevos rancheros recipe. Skipping meals and low-protein diets make things worse, not better. Avoid alcohol and sedatives. And treat any fever or bleeding as urgent.

How is HE treated, and what should patients expect?

ET: Treatment is two-part: find and fix the trigger and clear the toxins. Lactulose is the foundation. It's a laxative that flushes ammonia out through the gut. Rifaximin, an antibiotic that stays in the intestine, is added to prevent recurrences. Most people recover fully from an episode once the trigger is addressed, often within a day or two. Expect to be on lactulose long-term, expect the dose to be adjusted, and expect that reliable treatment makes the difference between a manageable condition and a revolving hospital door.

What should patients and caregivers know about living with this long-term?

ET: Three things. First, HE can be preventable and always treatable. Consistency with medication is key. Second, caregivers are the early-warning system; keep a mental baseline of what "normal" looks like and speak up when it drifts. Sometimes this causes strife. In clinic, I spend a lot of time asking patients to listen to their loved ones. Third, know what to do. If early signs are observed or bowel movements drop off, drink fluids and take extra lacture. Call the clinic; we have your back and we can adjust things by phone. Go to the ER if someone is very drowsy, can't hold a conversation, is disoriented about where they are or who you are, or if there's any vomiting of blood or black stool. Confusion that comes on fast is an emergency until proven otherwise.