I was diagnosed with HCV in 2007. Was told it looked like I had had it for 40 years. I already had cirrhosis. Lately I have been sleeping day an night. Now that has turned in total night/days reversed, I also smell a lot like ammonia when I pee. Sometimes I am getting cofused about simple activites and am having trouble remembering words. What do you think is happening?
You are experiencing the symptoms of Hepatic Encephalopathy (HE). A complication of cirrhosis.
Since you already have cirrhosis and it has become advanced you should be seeing a hepatologist at a liver transplant center. A individual gastroenterologist or other type of doctor is not qualified your advance liver disease. You need the resources of a team of doctors to properly manage all the complications a liver that is unable to function normally. Your hepatologist should be aware that you are experiencing HE and prescribe Lactulose and perhaps Xifaxan to manage your HE. HE only to get worse over time as you liver disease advances.
WHAT IS HEPATIC ENCEPHALOPATHY?
Dr Tim Davern California Pacific Medical Center
Under normal circumstances, ammonia is efficiently detoxified in the liver so that relatively little escapes into the general circulation bathing the brain. However, with advanced liver disease, whether acute or chronic, the detoxification of ammonia and other toxins by the liver fails, and they accumulate in the blood and disturb brain function.
Triggers that exacerbate underlying HE
Too much red meat
opiate pain medications and benzodiazepines
What are the symptoms of HE?
Patients suffering hepatic encephalopathy may come to the doctor with a spectrum of symptoms. In mild cases, called minimal hepatic encephalopathy, the patient may have no symptoms but have cognitive deficits revealed by formal neuropsychiatric testing (e.g., number connection tests, etc.). With more advanced hepatic encephalopathy, fatigue, and at least mild deficits of memory, concentration, and coordination may become apparent. At this stage, common complaints by the patient include:
- “I feel like my head is in the clouds.”
- “I’ll walk into a room and forget why I am there.”
- “I am always tired…but I can’t sleep.”
- “I often forget what to say in mid-sentence.”
- “My boss is telling me that my work is slipping.”
- “My handwriting has changed to scribble,”
- “My hands shake so much, I can’t hold my coffee cup without spilling it.”
Nighttime insomnia is a very common and troublesome symptom associated with hepatic encephalopathy. In fact, patients with encephalopathy may ultimately sleep more during the day, with fitful naps, than at night, and this “day-night reversal” is a hallmark of more advanced hepatic encephalopathy. Family and friends frequently notice a deterioration of the patient’s cognitive function as well as a change in the patient’s personality—with frequent irritability, bouts of anger, and loss of social graces. They may also witness firsthand deterioration of the patient’s driving skills (“He would have run off the road if I hadn’t grabbed the wheel!”).
Two of the most common physical (as opposed to subjective) manifestations of hepatic encephalopathy are asterixis and fetor hepaticus. Asterixis is a non-synchronous and coarse tremor– known colloquially as a “liver flap” – that is best elicited by asking the patient to outstretch the hands with straight elbows, wrists cocked at 90 degrees, and fingers spread apart, instructions easily communicated with the command, “Stop traffic!” Although such a tremor is not specific for hepatic encephalopathy (it can also be seen with renal failure and other conditions), it certainly suggests the diagnosis in patients with liver disease. Fetor hepaticus is a musty sweet odor that is usually evident by casually sniffing the patient’s breath.
When symptoms of hepatic encephalopathy progress, the patient may slip into a stupor or even comatose state and be virtually unarousable. Such situations are medical emergencies, and the patient should be brought to medical attention immediately.
How is hepatic encephalopathy diagnosed?
If present, an elevated blood ammonia level is helpful to confirm a diagnosis of hepatic encephalopathy, but a normal level does not completely rule out the diagnosis.
red meats should never be eaten. When they are digested they create a lot of anemia and other toxins that can effect the brain in a patient with a failing liver. Well-cooked poultry (chicken) and fish is acceptable; however, raw or undercooked shellfish (e.g., oysters) should be avoided to prevent infection with a number of pathogens, including Vibrio vulnificus, a rare but potentially serious infection in the setting of advanced cirrhosis.
Call your doctor tell them you are having symptoms of hepatic encephalopathy (total night/days reversed) they will set up an appointment and perform some tests and then prescribe drugs that will help you. As long as you have cirrhosis this if a complication of cirrhosis you will have to manage.
Here I am again. Boy oh boy, you should have been a doctor. That is the most accurate explanation for my condition. I forget everything . Get confused while driving. Hands shaking, I used to have great handwriting. My memory has gotten so bad I forget to take my meds and that's not good. I already know what I have, but with my mental and emotional problems, I know things will get worse. I know you are not a phyce doctor. But you make me feel safer knowing that you are out there. I hope you don't mind me reapting myself. But thank you thank you, thank you. I feel better. I get results tomorrow,from ultrasound and blood work for the umtheent tome/
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