Why do some people become confused or sleepy when they have cirrhosis?

Hepatic encephalopathy (HE) is a frequent but intermittent occurrence in many patients who are awaiting liver transplantation. One of the many jobs of the healthy liver is to clear toxins accumulated from food and metabolism from the bloodstream. When the amount of toxins produced exceeds the liver’s ability to clear those toxins from the bloodstream, the person develops HE. This condition results in a temporary change in thought processing. Early signs of HE include insomnia and daytime sleepiness, difficulty concentrating on tasks, and forgetfulness. Later stages are characterized by irritability and other changes in personality, confusion, and sleeping most of the time. HE can even cause coma. This problem usually has an inciting cause, such as gastrointestinal bleeding, poor dietary habits, electrolyte abnormalities, renal failure, infection, and skipped or excessive medication. In patients presenting with HE, each of these potential causes must be considered and treatment should be directed at reversal of the particular cause.

The initial treatment of HE consists of lactulose. Lactulose is a sweet, syrupy liquid that absorbs toxins and causes diarrhea. It should be dosed so that the patient achieves three to five soft, controllable bowel movements per day. The antibiotics neomycin and rifaximin may be substituted for lactulose or added later if needed.

Many patients with HE are advised to avoid high protein intake. Of all the food types, protein causes much more toxin buildup as compared with fats and carbohydrates. Unfortunately, limiting the intake of protein may result in malnutrition, strength loss, and weight loss, increasing the risk of infection and a poor outcome after transplantation. Protein restriction should be reserved for only patients with HE that cannot be controlled in any other way.