• Saad Maqsood
  • Amer Saleem
  • Adeel Iqbal
  • Javed Aslam Butt


Background: Hepatic encephalopathy is an extra hepatic complication of impaired liver functionand is manifested as neuropsychiatric signs and symptoms associated with acute or chronic liverdisease in the absence of other neurological disorders. There are numerous factors of hepaticencephalopathy. The main objective of this study was to analyse the precipitating factors ofhepatic encephalopathy in cases seen in Pakistan Institute of Medical Sciences Islamabad.Methods: Fifty admitted patients with acute or chronic liver diseases complicating to hepaticencephalopathy were probed into for precipitating factors, based on history, clinical examinationand laboratory methods from September 2005 to December 2005. The associated biochemicallaboratory data analysis and prognostic stratification through Child’s Pugh classification was alsodone. Results: Infection (44%), gastrointestinal bleeding (38%) and constipation (38%), stood outas the most common factors. Usage of drugs with ammonium salts, tranquilizers and large volumeparacentesis were least common factors. Most patients were in grade III (52%), and grade IV(22%), of hepatic encephalopathy. Other common associations were ascites (64%), Child’s class C(62%), hyponatremia (50%), low haemoglobin (70%), hepatitis C (62%), and high mortality rate(30%). Conclusion: Infection, gastrointestinal bleeding and constipation being the most importantprecipitating factors must be prevented and hospital funds, medicines and human efforts shouldlay emphasis, on these factors to decrease the incidence of hepatic encephalopathy. This alsoincludes effective control measures against rising cases of hepatitis C, as it is the leading cause ofliver cirrhosis in Pakistan.Key Words: Hepatic Encephalopathy, Liver cirrhosis, precipitating factors.


Ferenci P. Hepatic Encephalopathy. In: Haubrich WS,

Schaffner F, Berk JE, editors. Gastroenterolgy. 5 th edition.

Philadelphia: W.B. Saunders; 1995. 1988-2003.

Butterworth RF. The neurobiology of hepatic

encephalopathy. Semin Liv er Dis 1996; 16: 235-44.

Hamid S, Tabassum S, Jafri W. Hepatitis C has replaced

hepatitis B as major cause of chronic liver disease in

Pakistan. Hepatology 1990; 30: 212A.

Amodio P, Del Piccolo F, Marchetti P.. Clinical features and

survival of cirrhotic patients with subclinical cognitive

alterations dectected by the number connection test and

computerized psychometric tests. Hepatology 1999; 29: 1662

Watanabe A. Portal-systemic encephalopathy in non-cirrhotic

patients: classification of clinical types, diagnosis and

treatment. J. Gastroenterol. Hepatol. 2000; 15:969.

Sherlock S, Dooley J. Hepatic Encephalopathy. In: Disease

of the liver and biliary system. 11th edition. London:

Blackwell Science; 2002. 93.

Lizardi-Cervera J, Almeda P, Guevara L, Uribe M. Hepatic

encephalopathy: a review. Ann Hepatol. 2003; 2 (3): 122-30.

Conn HO. Effects of high-normal and low-normal serum

potassium levels on hepatic encephalopathy: facts, half-facts

or artifects? Hepatology 1994;20: 1637.

Batki G, Fisch HU, Karlaganis G, Minder C, Bircher J.

Mechanism of the excessive sedative response of cirrhotics to

benzodiazepines. Model experiments with triazolam.

Hepatology 1987; 7: 629.

Hazell AS, Butterworth RF. Hepatic encephalopathy: an

update of pathophysiologic mechanism. Proc. Soc. Exp. Biol.

Med. 1999; 222:99.

Cordoba J.Blei AT. Treatment of hepatic encephalopathy.

Am. J. Gastroenterol. 1997; 92: 1429.

J Ayub Med Coll Abbottabad 2006; 18(4)

Durrani AB, Rana AB Siddiqi HS, Marwat BU. The

spectrum of chronic liver disease in Balochistan. JCPSP

;11(2): 95-97.

Al-Gindan YM. Hepatic encephalopathy in Saudi Arabia.

Retrospective analysis of 51 patients. Indian J Med Sci 1992;

(3): 69-74.

Alam I, Razaullah, Haider I, Hamayun M, Taqweem A, Nisar

M. Spectrum of precipitating factors of hepatic

encephalopathy in liver cirrhosis. Pakistan J.Med. Res. 2005;

(2): 96-100.

Menon K.V. Pathogenesis, diagnosis and treatment of

alcoholic liver disease. Mayo Clinic Proc 2001; 76: 1021.

Strauss E, Costa MF. The importance of bacterial infection as

precipitating factor of chronic hepatic encephalopathy.

Hepatogastroenterology 1998;45:900-4.

Trom A, Griga T, Greving I, Hilden H, Schwegler H. Hepatic

encephalopathy in patients with cirrhosis and upper GI

bleeding. Hepatolgy 2000; 47:473-7.

Conn HO, Leiberlhal MM. The hepatic coma syndrome and

lactulose. 1st edition Baltimore: William and Wilkins, 1980;

Faloon WW, Evans GL. Precipitating factors in the genesis

of hepatic coma. NY State J Med 1970; 70: 2891.

Souheil Abu-Assi, Vlaeevie ZR. Hepatic encephalopathy:

metabolic consequences of the cirrhois are often reversible.

Post graduate Med 2001: 109:

Bustamante J, Rimola A, Ventura PJ, Navasa M, Cirera I,

Reggiardo V et al. Prognostic significance of hepatic

encephalopathy in patients with cirrhosis. J Hepatol. 1999;

: 890-95.

Shiekh S. Portal systemic encephalopathy in cirrhotic liver

disease. Experience at People Medical College, Nawabshah.

J Coll Physican Surg Pak 1998;8:53.

Sheikh A, Ahmed SI, Naseemullah M. Etiology of hepatic

encephalopathy and importance of upper gastrointestinal

bleeding and infections as precipitating factors. J Rawal Med

Coll 2001; 5:10.

Ahmed H, Rehman MU, Saeedi I, Shah D. Factors

precipitating hepatic encephalopathy in cirrhosis liver.

Postgrad Med Inst 2001; 15(1):91-7.

Khurram M, Khaar HB, Minhas Z, Javed S, Hassan Z,

Hameed TA et al. An experience of cirrhotic hepatic

encephalopathy at DHQ teaching hospital. J Rawal Med Coll

; 5: 60.

Kuramitsu T, Komatsu M, Matsudaira N, Naganuma T,

Niizawa M, Zeniya A et al. Portal systemic encephalopathy

from a spontaneous gastrorenal shunt diagnosed by three

dimensional computed tomography and treated effectively by

percutanous vascular embolization. Liver 1998;18:208.

Cordoba J, Blei AT. Treatment of hepatic encephalopathy.

Ann. J. Gastrenterol. 1997;92:1429.

Olga OZ, Nikolai DY. Invasive and non invasive monitoring

of hepatitis C virus induced liver cirrhosis: alternates or

complements? Curr Pharm Biotechnol 2003; 4(3): 195-209.


Fessel JM, Conn HO. An analysis of the causes and

prevention of hepatic coma. Gastroenterolgy1972; 62: 191.