INFO: Brain Fog - Treating Hepatic Encephalopathy - Lactulose and Antibiotics - Diet limiting protein

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What about “Brain Fog”?Hepatic encephalopathy should not be confused with “brain fog”—the mild lack of concentration, forgetfulness, or absent-mindedness that is common in people with chronic hepatitis C and those receiving HCV treatment. Several studies have shown some degree of cognitive impairment, memory problems, and reduced concentration in people with hepatitis C who do not have advanced disease. The cause of “brain fog” is not well understood. Some experts believe that HCV itself may affect the central nervous system, or that the virus may alter or stimulate the immune system in ways that impact the brain. In addition, “brain fog” may be related to fatigue, lack of sleep, stress, depression, or side effects of interferon. But in people without advanced cirrhosis, the liver is usually still able to process toxins and blood usually still flows well through the liver. Thus, “brain fog” cannot be assumed to be an early manifestation of hepatic

encephalopathy—even though the signs of “brain fog” and some of the symptoms of grade 0 or grade 1 encephalopathy may be similar. Treating Hepatic EncephalopathyHepatic encephalopathy in people with chronic hepatitis can usually be treated, and symptoms are generally reversible once metabolic abnormalities are corrected. (This is less likely to be the case for those with encephalopathy due to fulminant liver failure, which is often fatal). Whenever possible, precipitating causes should be identified and dealt with as first step. The primary goal of treatment is to eliminate or neutralize toxins such as ammonia in the intestines. The first line treatment is lactulose, a nondigestible sugar. Lactulose alters the metabolism of intestinal bacteria, makes the gut environment more acidic, and acts as a laxative. It inhibits intestinal ammonia production and absorption and increases elimination in the stool. Studies have shown that lactulose (available as

a syrup or an enema) is safe and effective. It causes loose stools or diarrhea as part of its mechanism of action. It can be used long-term to prevent hepatic encephalopathy symptoms in patients prone to frequent recurrences. Antibiotics may also be used to reduce the amount of toxins produced by intestinal bacteria; this is usually tried if lactulose is ineffective. Metronidazole (Flagyl), neomycin, or paromomycin may be used, but long-term administration of neomycin can cause ear and kidney damage. Sodium benzoate and ornithine aspartate can be used to bind ammonia and increase its elimination in the urine. Other potential therapies—which have had mixed results in clinical trials­—include flumazenil, levodopa, bromocriptine, levocarnitine, and zinc. In the past, strict diet modification was seen as a mainstay of liver disease management, but this is less true today. The body needs sufficient protein for tissue maintenance repair, and long-term

low-protein diets are not usually recommended for people with cirrhosis because they can lead to malnutrition. However, limiting protein consumption for short periods can decrease blood ammonia levels and reduce encephalopathy symptoms. Many experts recommend eating proteins from vegetable sources—or from dairy products, fish, or chicken—rather than from red meat. In severe cases, dietary supplements containing branched-chain amino acids may be used. Patients who have progressed to hepatic coma may require intubation, mechanical respiration, and cardiac life support. People with end-stage liver disease should be considered for a liver transplant. Hepatic encephalopathy can rapidly progress to become an acute emergency condition, but even mild encephalopathy can have a detrimental effect on the quality of life of people with chronic hepatitis. Alert your health-care provider promptly if you notice any changes in mental status, intellectual functioning, level

of alertness, or motor function so that you can be evaluated and treated without delay. http://www.hcvadvocate.org/hepatitis/hepC/hepatic_encephalopathy.html