Liver diseases remain a major health concern in developing countries like India, with a rising burden of chronic liver disease (CLD) impacting the economy. Hepatic encephalopathy (HE), also known as portosystemic encephalopathy, is a severe complication of chronic liver disease, characterized by altered mental status and cognitive dysfunction. It is reversible with early diagnosis and treatment but significantly impacts quality of life and survival. Nearly 70% of patients have subtle symptoms, while 30-45% of cirrhotic individuals develop overt HE.1 Ammonia, produced by gut bacteria, is processed by the liver, but impaired clearance due to portosystemic shunting leads to hyperammonemia. Hepatic encephalopathy results from neurotoxic accumulation in the blood and brain. The correlation between ammonia levels and HE severity is inconsistent. Other contributing factors include false neurotransmitters and mercaptans. Minimal hepatic encephalopathy presents with subtle symptoms, detectable only through specialized tests.2,3

Hepatic encephalopathy is diagnosed clinically, requiring a skilled physician to recognize its varied symptoms. Patients may present with confusion, personality changes, aggression, or excessive drowsiness. In severe cases, it can progress to hepatic coma, which may be fatal. Identifying precipitating factors is crucial for timely management. Asterixis, or "liver flap," is a common finding in hepatic encephalopathy, induced by asking patients to extend their arms and bend their wrists back. The West Haven criteria are widely used for grading HE. While ammonia levels are often elevated, they are not a reliable diagnostic marker. Most HE episodes in cirrhotic patients result from identifiable precipitating factors or spontaneous portosystemic shunting.4

Common precipitating factors of hepatic encephalopathy include GI bleeding, infections, hypovolemia, azotemia, constipation, electrolyte imbalance, and high protein intake, with infections and GI bleeding being the most frequent. Management involves ruling out other causes, identifying triggers, and assessing response to empirical treatment. Lactulose and rifaximin, approved by the FDA, help reduce ammonia production and absorption. Early detection and prompt management of precipitating factors are crucial for better patient outcomes.5,6 Therefore this study aimed to analyze the clinical profile of HE in cirrhosis, identify precipitating factors, and assess their correlation with outcomes.

A hospital-based descriptive study was conducted over 18 months (August 2022 to February 2024) on 440 patients with chronic liver disease (CLD) and hepatic encephalopathy (HE) using a complete enumeration method. Following ethical committee approval, patients aged 18–60 years with cirrhosis and HE symptoms were included, while those with acute CNS infections, neuropsychiatric disorders, acute alcoholic intoxication, alcohol withdrawal, fulminant hepatitis, or non-cirrhotic portal hypertension were excluded. Data collection involved clinical history, drug usage, alcohol intake, and neurological and abdominal signs. HE was graded using the West Haven criteria, and cirrhosis severity was assessed using the Child-Turcotte-Pugh score. Investigations included CBC, renal function tests, serum electrolytes, LFT, coagulation profile, PT-INR, serum proteins, ultrasound, viral markers (HBsAg, Anti-HCV), and ascitic fluid analysis. Patients were followed throughout hospitalization, with outcomes recorded. Data was collected using a predesigned questionnaire covering socio-demographics, clinical history, diagnosis, and treatment. Standard investigations were performed, and results were analysed.

Statistical Analysis

Data were compiled using descriptive statistics in Microsoft Excel 2019. Statistical analysis was done using SPSS software. Qualitative data was represented in the form of frequency and percentage.

Most of the patients belong to the age group of 41 to 50 years (37.9%) followed by age group of 51 to 60 years (25.0%) with median age of 46.3 years with male predominance (88.8%) as shown in table 1.

Table 1: Demographic data of patients

Disorientation (75.9%), confusion (75.6%) and abdominal symptom (69.0%) were the commonest presenting symptoms. The commonest signs were asterixis (74%), pedal oedema (62%), icterus (60%), ascites (60.6%) and pallor (59.0%), (Table 2).

Table 2: Presenting sign and symptoms

Table3: Mortalityaccordingtovarious study parameters

30% of patients experienced mortality, while 70% survived. This indicates a relatively high survival rate among the patients studied, (Table 4).

Table 4: Mortality rate

The identification and treatment of the precipitating factor is the most important aspect of the management of acute HE since symptoms of overt HE are debilitating and lead to non-adherence to a therapeutic regimen, which, in turn, leads to severe symptoms, frequent hospitalizations, and poor quality of life.7 In the present study, the majority of patients were found to have HE in their 4th and 5th decades of life. Similar findings were observed by Barbosa M. et al8, who reported that most HE patients were in their 5th decade of life. Groeneweg et al9also stated that chronic liver disease patients who developed hepatic encephalopathy were elderly. The male predominant population in this study is likely due to the risk of chronic alcohol use as a cause of liver disease which was consistent with other studies.9,10

The major cause of hepatic encephalopathy was alcohol usage, constituting about 60% of the total cases. Viral hepatitis and other unknown causes constituted to about 20% in each. Duah A et al also found that the cause of liver cirrhosis was significant alcohol consumption and hepatitis B virus in 44.9% and 43.7% of the cases.11 Poudyal NS et al also found the most common cause of chronic liver disease to be alcohol - 114 (86%), followed by hepatitis B virus - nine (7%).12

The most common precipitating factors in the present study were constipation (45%), malena (32.9%) and haematemesis in 28% of the cases. Similar findings were noticed by Maqsood S.et al13and VeeraballiS. et al.14

60% of the subjects in our study showed CHILD-PUGH score belonging to “C” category. Similar findings were noticed by Maqsood S. et al13where they found 62% of the subjects with “C” CHILD PUGH score. Another study by Mumtaz K. et al shows similar findings of 78% population belonging to class C Child pugh score.15 Majority of population in current study falls under West Haven grade 3(30% of the population) followed by grade 4 (28% of the population) and grade 1(28% of the population. In a study conducted by Maqsood S. et al13,52% of the population belongs to West haven grade 3 and 22% of the population belongs to West Haven grade 4. Similar findings were present in a study conducted by Raphael KC et al16where 36.4% of population belonging to West Haven grade 3 and 18.2% of the population belonging to West Haven grade 4.

The mortality rate in the present study accounts to 30% of the population. Study done by Y M Al-Gindan et al17 has findings with mortality rate of 41% in a population of 51. Another study conducted by Maqsood S. et al13 has similar mortality rate of 30%. Raphael KC et al16study in 2016 reveals mortality rate of 75%.In the present study carried out on the population of 440, 132 patients expired due to Hepatic Encephalopathy and 13 patients expired due to other unexplained causes.

In conclusion, hepatic encephalopathy is a common complication in liver cirrhosis, often triggered by factors such as upper GI bleeding, infections, diuretics, electrolyte imbalances, and constipation. Raising awareness among cirrhotic patients about these risks is essential. Preventive measures, including timely infection control, regular GI monitoring, proper laxative use, cautious administration of sedatives and diuretics, and appropriate dietary guidance, should be integral to patient care. Early identification and management of precipitating factors can significantly reduce mortality and improve outcomes.

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