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class="vector-toc-numb">2</span> <span>Causes</span> </div> </a> <ul id="toc-Causes-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Pathogenesis" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#Pathogenesis"> <div class="vector-toc-text"> <span class="vector-toc-numb">3</span> <span>Pathogenesis</span> </div> </a> <ul id="toc-Pathogenesis-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Diagnosis" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#Diagnosis"> <div class="vector-toc-text"> <span class="vector-toc-numb">4</span> <span>Diagnosis</span> </div> </a> <button aria-controls="toc-Diagnosis-sublist" class="cdx-button cdx-button--weight-quiet cdx-button--icon-only vector-toc-toggle"> <span class="vector-icon mw-ui-icon-wikimedia-expand"></span> <span>Toggle Diagnosis subsection</span> </button> <ul id="toc-Diagnosis-sublist" class="vector-toc-list"> <li id="toc-Investigations" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#Investigations"> <div class="vector-toc-text"> <span class="vector-toc-numb">4.1</span> <span>Investigations</span> </div> </a> <ul id="toc-Investigations-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Classification" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#Classification"> <div class="vector-toc-text"> <span class="vector-toc-numb">4.2</span> <span>Classification</span> </div> </a> <ul id="toc-Classification-sublist" class="vector-toc-list"> <li id="toc-West_Haven_criteria" class="vector-toc-list-item vector-toc-level-3"> <a class="vector-toc-link" href="#West_Haven_criteria"> <div class="vector-toc-text"> <span class="vector-toc-numb">4.2.1</span> <span>West Haven criteria</span> </div> </a> <ul id="toc-West_Haven_criteria-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Types" class="vector-toc-list-item vector-toc-level-3"> <a class="vector-toc-link" href="#Types"> <div class="vector-toc-text"> <span class="vector-toc-numb">4.2.2</span> <span>Types</span> </div> </a> <ul id="toc-Types-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Minimal_HE" class="vector-toc-list-item vector-toc-level-3"> <a class="vector-toc-link" href="#Minimal_HE"> <div class="vector-toc-text"> <span class="vector-toc-numb">4.2.3</span> <span>Minimal HE</span> </div> </a> <ul id="toc-Minimal_HE-sublist" class="vector-toc-list"> </ul> </li> </ul> </li> </ul> </li> <li id="toc-Treatment" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#Treatment"> <div class="vector-toc-text"> <span class="vector-toc-numb">5</span> <span>Treatment</span> </div> </a> <button aria-controls="toc-Treatment-sublist" class="cdx-button cdx-button--weight-quiet cdx-button--icon-only vector-toc-toggle"> <span class="vector-icon mw-ui-icon-wikimedia-expand"></span> <span>Toggle Treatment subsection</span> </button> <ul id="toc-Treatment-sublist" class="vector-toc-list"> <li id="toc-Diet" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#Diet"> <div class="vector-toc-text"> <span class="vector-toc-numb">5.1</span> <span>Diet</span> </div> </a> <ul id="toc-Diet-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Lactulose/lactitol" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#Lactulose/lactitol"> <div class="vector-toc-text"> <span class="vector-toc-numb">5.2</span> <span>Lactulose/lactitol</span> </div> </a> <ul id="toc-Lactulose/lactitol-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-Antibiotics" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#Antibiotics"> <div class="vector-toc-text"> <span class="vector-toc-numb">5.3</span> <span>Antibiotics</span> </div> </a> <ul id="toc-Antibiotics-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-L-Ornithine_and_L-aspartate" class="vector-toc-list-item vector-toc-level-2"> <a class="vector-toc-link" href="#L-Ornithine_and_L-aspartate"> <div class="vector-toc-text"> <span class="vector-toc-numb">5.4</span> <span>L-Ornithine and L-aspartate</span> </div> </a> <ul id="toc-L-Ornithine_and_L-aspartate-sublist" class="vector-toc-list"> </ul> </li> </ul> </li> <li id="toc-Epidemiology_and_prognosis" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#Epidemiology_and_prognosis"> <div class="vector-toc-text"> <span class="vector-toc-numb">6</span> <span>Epidemiology and prognosis</span> </div> </a> <ul id="toc-Epidemiology_and_prognosis-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-History" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#History"> <div class="vector-toc-text"> <span class="vector-toc-numb">7</span> <span>History</span> </div> </a> <ul id="toc-History-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-References" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#References"> <div class="vector-toc-text"> <span class="vector-toc-numb">8</span> <span>References</span> </div> </a> <ul id="toc-References-sublist" class="vector-toc-list"> </ul> </li> <li id="toc-External_links" class="vector-toc-list-item vector-toc-level-1 vector-toc-list-item-expanded"> <a class="vector-toc-link" href="#External_links"> <div class="vector-toc-text"> <span class="vector-toc-numb">9</span> <span>External links</span> </div> </a> <ul id="toc-External_links-sublist" class="vector-toc-list"> </ul> </li> </ul> </div> </div> </nav> </div> </div> <div class="mw-content-container"> <main id="content" class="mw-body"> <header class="mw-body-header vector-page-titlebar"> <nav aria-label="Contents" class="vector-toc-landmark"> <div id="vector-page-titlebar-toc" class="vector-dropdown vector-page-titlebar-toc vector-button-flush-left" > <input type="checkbox" id="vector-page-titlebar-toc-checkbox" role="button" aria-haspopup="true" data-event-name="ui.dropdown-vector-page-titlebar-toc" class="vector-dropdown-checkbox " aria-label="Toggle the table of contents" > <label id="vector-page-titlebar-toc-label" for="vector-page-titlebar-toc-checkbox" class="vector-dropdown-label cdx-button cdx-button--fake-button cdx-button--fake-button--enabled cdx-button--weight-quiet cdx-button--icon-only " aria-hidden="true" ><span class="vector-icon mw-ui-icon-listBullet mw-ui-icon-wikimedia-listBullet"></span> <span class="vector-dropdown-label-text">Toggle the table of contents</span> </label> <div class="vector-dropdown-content"> <div id="vector-page-titlebar-toc-unpinned-container" class="vector-unpinned-container"> </div> </div> </div> </nav> <h1 id="firstHeading" class="firstHeading mw-first-heading"><span class="mw-page-title-main">Hepatic encephalopathy</span></h1> <div id="p-lang-btn" class="vector-dropdown mw-portlet mw-portlet-lang" > <input type="checkbox" id="p-lang-btn-checkbox" role="button" aria-haspopup="true" data-event-name="ui.dropdown-p-lang-btn" class="vector-dropdown-checkbox mw-interlanguage-selector" aria-label="Go to an article in another language. Available in 32 languages" > <label id="p-lang-btn-label" for="p-lang-btn-checkbox" class="vector-dropdown-label cdx-button cdx-button--fake-button cdx-button--fake-button--enabled cdx-button--weight-quiet cdx-button--action-progressive mw-portlet-lang-heading-32" aria-hidden="true" ><span class="vector-icon mw-ui-icon-language-progressive mw-ui-icon-wikimedia-language-progressive"></span> <span class="vector-dropdown-label-text">32 languages</span> </label> <div class="vector-dropdown-content"> <div class="vector-menu-content"> <ul class="vector-menu-content-list"> <li class="interlanguage-link interwiki-ar mw-list-item"><a href="https://ar.wikipedia.org/wiki/%D8%A7%D8%B9%D8%AA%D9%84%D8%A7%D9%84_%D8%AF%D9%85%D8%A7%D8%BA%D9%8A_%D9%83%D8%A8%D8%AF%D9%8A" title="اعتلال دماغي كبدي – Arabic" lang="ar" hreflang="ar" data-title="اعتلال دماغي كبدي" data-language-autonym="العربية" data-language-local-name="Arabic" class="interlanguage-link-target"><span>العربية</span></a></li><li class="interlanguage-link interwiki-az mw-list-item"><a href="https://az.wikipedia.org/wiki/Hepatik_ensefalopatiya" title="Hepatik ensefalopatiya – Azerbaijani" lang="az" hreflang="az" data-title="Hepatik ensefalopatiya" data-language-autonym="Azərbaycanca" data-language-local-name="Azerbaijani" class="interlanguage-link-target"><span>Azərbaycanca</span></a></li><li class="interlanguage-link interwiki-ca mw-list-item"><a href="https://ca.wikipedia.org/wiki/Encefalopatia_hep%C3%A0tica" title="Encefalopatia hepàtica – Catalan" lang="ca" hreflang="ca" data-title="Encefalopatia hepàtica" data-language-autonym="Català" data-language-local-name="Catalan" class="interlanguage-link-target"><span>Català</span></a></li><li class="interlanguage-link interwiki-da mw-list-item"><a href="https://da.wikipedia.org/wiki/Hepatisk_encefalopati" title="Hepatisk encefalopati – Danish" lang="da" hreflang="da" data-title="Hepatisk encefalopati" data-language-autonym="Dansk" data-language-local-name="Danish" class="interlanguage-link-target"><span>Dansk</span></a></li><li class="interlanguage-link interwiki-de mw-list-item"><a href="https://de.wikipedia.org/wiki/Hepatische_Enzephalopathie" title="Hepatische Enzephalopathie – German" lang="de" hreflang="de" data-title="Hepatische Enzephalopathie" data-language-autonym="Deutsch" data-language-local-name="German" class="interlanguage-link-target"><span>Deutsch</span></a></li><li class="interlanguage-link interwiki-es mw-list-item"><a href="https://es.wikipedia.org/wiki/Encefalopat%C3%ADa_hep%C3%A1tica" title="Encefalopatía hepática – Spanish" lang="es" hreflang="es" data-title="Encefalopatía hepática" data-language-autonym="Español" data-language-local-name="Spanish" class="interlanguage-link-target"><span>Español</span></a></li><li class="interlanguage-link interwiki-eo mw-list-item"><a href="https://eo.wikipedia.org/wiki/Hepata_encefalopatio" title="Hepata encefalopatio – Esperanto" lang="eo" hreflang="eo" data-title="Hepata encefalopatio" data-language-autonym="Esperanto" data-language-local-name="Esperanto" class="interlanguage-link-target"><span>Esperanto</span></a></li><li class="interlanguage-link interwiki-fa mw-list-item"><a href="https://fa.wikipedia.org/wiki/%D8%A7%D9%86%D8%B3%D9%81%D8%A7%D9%84%D9%88%D9%BE%D8%A7%D8%AA%DB%8C_%DA%A9%D8%A8%D8%AF%DB%8C" title="انسفالوپاتی کبدی – Persian" lang="fa" hreflang="fa" data-title="انسفالوپاتی کبدی" data-language-autonym="فارسی" data-language-local-name="Persian" class="interlanguage-link-target"><span>فارسی</span></a></li><li class="interlanguage-link interwiki-fr mw-list-item"><a href="https://fr.wikipedia.org/wiki/Enc%C3%A9phalopathie_h%C3%A9patique" title="Encéphalopathie hépatique – French" lang="fr" hreflang="fr" data-title="Encéphalopathie hépatique" data-language-autonym="Français" data-language-local-name="French" class="interlanguage-link-target"><span>Français</span></a></li><li class="interlanguage-link interwiki-ko badge-Q17437798 badge-goodarticle mw-list-item" title="good article badge"><a href="https://ko.wikipedia.org/wiki/%EA%B0%84%EC%84%B1_%EB%87%8C%EC%A6%9D" title="간성 뇌증 – Korean" lang="ko" hreflang="ko" data-title="간성 뇌증" data-language-autonym="한국어" data-language-local-name="Korean" class="interlanguage-link-target"><span>한국어</span></a></li><li class="interlanguage-link interwiki-hy mw-list-item"><a href="https://hy.wikipedia.org/wiki/%D4%BC%D5%B5%D5%A1%D6%80%D5%A4%D5%A1%D5%B5%D5%AB%D5%B6_%D5%A7%D5%B6%D6%81%D5%A5%D6%86%D5%A1%D5%AC%D5%B8%D5%BA%D5%A1%D5%A9%D5%AB%D5%A1" title="Լյարդային էնցեֆալոպաթիա – Armenian" lang="hy" hreflang="hy" data-title="Լյարդային էնցեֆալոպաթիա" data-language-autonym="Հայերեն" data-language-local-name="Armenian" class="interlanguage-link-target"><span>Հայերեն</span></a></li><li class="interlanguage-link interwiki-id mw-list-item"><a href="https://id.wikipedia.org/wiki/Ensefalopati_hepatik" title="Ensefalopati hepatik – Indonesian" lang="id" hreflang="id" data-title="Ensefalopati hepatik" data-language-autonym="Bahasa Indonesia" data-language-local-name="Indonesian" class="interlanguage-link-target"><span>Bahasa Indonesia</span></a></li><li class="interlanguage-link interwiki-it badge-Q17437798 badge-goodarticle mw-list-item" title="good article badge"><a href="https://it.wikipedia.org/wiki/Encefalopatia_epatica" title="Encefalopatia epatica – Italian" lang="it" hreflang="it" data-title="Encefalopatia epatica" data-language-autonym="Italiano" data-language-local-name="Italian" class="interlanguage-link-target"><span>Italiano</span></a></li><li class="interlanguage-link interwiki-he mw-list-item"><a href="https://he.wikipedia.org/wiki/%D7%90%D7%A0%D7%A6%D7%A4%D7%9C%D7%95%D7%A4%D7%AA%D7%99%D7%94_%D7%9B%D7%91%D7%93%D7%99%D7%AA" title="אנצפלופתיה כבדית – Hebrew" lang="he" hreflang="he" data-title="אנצפלופתיה כבדית" data-language-autonym="עברית" data-language-local-name="Hebrew" class="interlanguage-link-target"><span>עברית</span></a></li><li class="interlanguage-link interwiki-nl mw-list-item"><a href="https://nl.wikipedia.org/wiki/Hepatische_encefalopathie" title="Hepatische encefalopathie – Dutch" lang="nl" hreflang="nl" data-title="Hepatische encefalopathie" data-language-autonym="Nederlands" data-language-local-name="Dutch" class="interlanguage-link-target"><span>Nederlands</span></a></li><li class="interlanguage-link interwiki-ja mw-list-item"><a href="https://ja.wikipedia.org/wiki/%E8%82%9D%E6%80%A7%E8%84%B3%E7%97%87" title="肝性脳症 – Japanese" lang="ja" hreflang="ja" data-title="肝性脳症" data-language-autonym="日本語" data-language-local-name="Japanese" class="interlanguage-link-target"><span>日本語</span></a></li><li class="interlanguage-link interwiki-or mw-list-item"><a href="https://or.wikipedia.org/wiki/%E0%AC%B9%E0%AD%87%E0%AC%AA%E0%AC%BE%E0%AC%9F%E0%AC%BF%E0%AC%95_%E0%AC%8F%E0%AC%A8%E0%AC%B8%E0%AD%87%E0%AC%AB%E0%AC%BE%E0%AC%B2%E0%AD%8B%E0%AC%AA%E0%AC%BE%E0%AC%A5%E0%AC%BF" title="ହେପାଟିକ ଏନସେଫାଲୋପାଥି – Odia" lang="or" hreflang="or" data-title="ହେପାଟିକ ଏନସେଫାଲୋପାଥି" data-language-autonym="ଓଡ଼ିଆ" data-language-local-name="Odia" class="interlanguage-link-target"><span>ଓଡ଼ିଆ</span></a></li><li class="interlanguage-link interwiki-uz badge-Q17559452 badge-recommendedarticle mw-list-item" title="recommended article"><a href="https://uz.wikipedia.org/wiki/Jigar_ensefalopatiyasi" title="Jigar ensefalopatiyasi – Uzbek" lang="uz" hreflang="uz" data-title="Jigar ensefalopatiyasi" data-language-autonym="Oʻzbekcha / ўзбекча" data-language-local-name="Uzbek" class="interlanguage-link-target"><span>Oʻzbekcha / ўзбекча</span></a></li><li class="interlanguage-link interwiki-pl mw-list-item"><a href="https://pl.wikipedia.org/wiki/Encefalopatia_w%C4%85trobowa" title="Encefalopatia wątrobowa – Polish" lang="pl" hreflang="pl" data-title="Encefalopatia wątrobowa" data-language-autonym="Polski" data-language-local-name="Polish" class="interlanguage-link-target"><span>Polski</span></a></li><li class="interlanguage-link interwiki-pt mw-list-item"><a href="https://pt.wikipedia.org/wiki/Encefalopatia_hep%C3%A1tica" title="Encefalopatia hepática – Portuguese" lang="pt" hreflang="pt" data-title="Encefalopatia hepática" data-language-autonym="Português" data-language-local-name="Portuguese" class="interlanguage-link-target"><span>Português</span></a></li><li class="interlanguage-link interwiki-ru mw-list-item"><a href="https://ru.wikipedia.org/wiki/%D0%9F%D0%B5%D1%87%D1%91%D0%BD%D0%BE%D1%87%D0%BD%D0%B0%D1%8F_%D0%BA%D0%BE%D0%BC%D0%B0" title="Печёночная кома – Russian" lang="ru" hreflang="ru" data-title="Печёночная кома" data-language-autonym="Русский" data-language-local-name="Russian" class="interlanguage-link-target"><span>Русский</span></a></li><li class="interlanguage-link interwiki-sl mw-list-item"><a href="https://sl.wikipedia.org/wiki/Jetrna_encefalopatija" title="Jetrna encefalopatija – Slovenian" lang="sl" hreflang="sl" data-title="Jetrna encefalopatija" data-language-autonym="Slovenščina" data-language-local-name="Slovenian" class="interlanguage-link-target"><span>Slovenščina</span></a></li><li class="interlanguage-link interwiki-sr mw-list-item"><a href="https://sr.wikipedia.org/wiki/%D0%A5%D0%B5%D0%BF%D0%B0%D1%82%D0%B8%D1%87%D0%BA%D0%B0_%D0%BA%D0%BE%D0%BC%D0%B0" title="Хепатичка кома – Serbian" lang="sr" hreflang="sr" data-title="Хепатичка кома" data-language-autonym="Српски / srpski" data-language-local-name="Serbian" class="interlanguage-link-target"><span>Српски / srpski</span></a></li><li class="interlanguage-link interwiki-sh mw-list-item"><a href="https://sh.wikipedia.org/wiki/Hepati%C4%8Dka_koma" title="Hepatička koma – Serbo-Croatian" lang="sh" hreflang="sh" data-title="Hepatička koma" data-language-autonym="Srpskohrvatski / српскохрватски" data-language-local-name="Serbo-Croatian" class="interlanguage-link-target"><span>Srpskohrvatski / српскохрватски</span></a></li><li class="interlanguage-link interwiki-fi mw-list-item"><a href="https://fi.wikipedia.org/wiki/Hepaattinen_enkefalopatia" title="Hepaattinen enkefalopatia – Finnish" lang="fi" hreflang="fi" data-title="Hepaattinen enkefalopatia" data-language-autonym="Suomi" data-language-local-name="Finnish" class="interlanguage-link-target"><span>Suomi</span></a></li><li class="interlanguage-link interwiki-sv mw-list-item"><a href="https://sv.wikipedia.org/wiki/Leverkoma" title="Leverkoma – Swedish" lang="sv" hreflang="sv" data-title="Leverkoma" data-language-autonym="Svenska" data-language-local-name="Swedish" class="interlanguage-link-target"><span>Svenska</span></a></li><li class="interlanguage-link interwiki-ta mw-list-item"><a href="https://ta.wikipedia.org/wiki/%E0%AE%95%E0%AE%B2%E0%AF%8D%E0%AE%B2%E0%AF%80%E0%AE%B0%E0%AE%B2%E0%AF%8D%E0%AE%A8%E0%AF%8B%E0%AE%AF%E0%AF%8D_%E0%AE%AE%E0%AF%82%E0%AE%B3%E0%AF%88%E0%AE%95%E0%AF%8D%E0%AE%95%E0%AF%8B%E0%AE%B3%E0%AE%BE%E0%AE%B1%E0%AF%81" title="கல்லீரல்நோய் மூளைக்கோளாறு – Tamil" lang="ta" hreflang="ta" data-title="கல்லீரல்நோய் மூளைக்கோளாறு" data-language-autonym="தமிழ்" data-language-local-name="Tamil" class="interlanguage-link-target"><span>தமிழ்</span></a></li><li class="interlanguage-link interwiki-th mw-list-item"><a href="https://th.wikipedia.org/wiki/%E0%B9%82%E0%B8%A3%E0%B8%84%E0%B8%AA%E0%B8%A1%E0%B8%AD%E0%B8%87%E0%B8%88%E0%B8%B2%E0%B8%81%E0%B8%95%E0%B8%B1%E0%B8%9A" title="โรคสมองจากตับ – Thai" lang="th" hreflang="th" data-title="โรคสมองจากตับ" data-language-autonym="ไทย" data-language-local-name="Thai" class="interlanguage-link-target"><span>ไทย</span></a></li><li class="interlanguage-link interwiki-tr mw-list-item"><a href="https://tr.wikipedia.org/wiki/Hepatik_ensefalopati" title="Hepatik ensefalopati – Turkish" lang="tr" hreflang="tr" data-title="Hepatik ensefalopati" data-language-autonym="Türkçe" data-language-local-name="Turkish" class="interlanguage-link-target"><span>Türkçe</span></a></li><li class="interlanguage-link interwiki-uk mw-list-item"><a href="https://uk.wikipedia.org/wiki/%D0%9F%D0%B5%D1%87%D1%96%D0%BD%D0%BA%D0%BE%D0%B2%D0%B0_%D0%B5%D0%BD%D1%86%D0%B5%D1%84%D0%B0%D0%BB%D0%BE%D0%BF%D0%B0%D1%82%D1%96%D1%8F" title="Печінкова енцефалопатія – Ukrainian" lang="uk" hreflang="uk" data-title="Печінкова енцефалопатія" data-language-autonym="Українська" data-language-local-name="Ukrainian" class="interlanguage-link-target"><span>Українська</span></a></li><li class="interlanguage-link interwiki-vi mw-list-item"><a href="https://vi.wikipedia.org/wiki/B%E1%BB%87nh_n%C3%A3o_gan" title="Bệnh não gan – Vietnamese" lang="vi" hreflang="vi" data-title="Bệnh não gan" data-language-autonym="Tiếng Việt" data-language-local-name="Vietnamese" class="interlanguage-link-target"><span>Tiếng Việt</span></a></li><li class="interlanguage-link interwiki-zh mw-list-item"><a href="https://zh.wikipedia.org/wiki/%E8%82%9D%E6%80%A7%E8%84%91%E7%97%85" title="肝性脑病 – Chinese" lang="zh" hreflang="zh" data-title="肝性脑病" data-language-autonym="中文" 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data-mw-ve-target-container> <div class="vector-body-before-content"> <div class="mw-indicators"> <div id="mw-indicator-good-star" class="mw-indicator"><div class="mw-parser-output"><span typeof="mw:File"><a href="/wiki/Wikipedia:Good_articles*" title="This is a good article. 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Click here for more information." src="//upload.wikimedia.org/wikipedia/en/thumb/9/94/Symbol_support_vote.svg/19px-Symbol_support_vote.svg.png" decoding="async" width="19" height="20" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/en/thumb/9/94/Symbol_support_vote.svg/29px-Symbol_support_vote.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/9/94/Symbol_support_vote.svg/39px-Symbol_support_vote.svg.png 2x" data-file-width="180" data-file-height="185" /></a></span></div></div> </div> <div id="siteSub" class="noprint">From Wikipedia, the free encyclopedia</div> </div> <div id="contentSub"><div id="mw-content-subtitle"></div></div> <div id="mw-content-text" class="mw-body-content"><div class="mw-content-ltr mw-parser-output" lang="en" dir="ltr"><div class="shortdescription nomobile noexcerpt noprint searchaux" style="display:none">Brain disease resulting from liver failure</div> <p class="mw-empty-elt"> </p> <div class="shortdescription nomobile noexcerpt noprint searchaux" style="display:none">Medical condition</div><style data-mw-deduplicate="TemplateStyles:r1257001546">.mw-parser-output .infobox-subbox{padding:0;border:none;margin:-3px;width:auto;min-width:100%;font-size:100%;clear:none;float:none;background-color:transparent}.mw-parser-output .infobox-3cols-child{margin:auto}.mw-parser-output .infobox .navbar{font-size:100%}@media screen{html.skin-theme-clientpref-night .mw-parser-output .infobox-full-data:not(.notheme)>div:not(.notheme)[style]{background:#1f1f23!important;color:#f8f9fa}}@media screen and (prefers-color-scheme:dark){html.skin-theme-clientpref-os .mw-parser-output .infobox-full-data:not(.notheme) div:not(.notheme){background:#1f1f23!important;color:#f8f9fa}}@media(min-width:640px){body.skin--responsive .mw-parser-output .infobox-table{display:table!important}body.skin--responsive .mw-parser-output .infobox-table>caption{display:table-caption!important}body.skin--responsive .mw-parser-output .infobox-table>tbody{display:table-row-group}body.skin--responsive .mw-parser-output .infobox-table tr{display:table-row!important}body.skin--responsive .mw-parser-output .infobox-table th,body.skin--responsive .mw-parser-output .infobox-table td{padding-left:inherit;padding-right:inherit}}</style><table class="infobox ib-medical-condition"><tbody><tr><th colspan="2" class="infobox-above" style="background:#ccc">Hepatic encephalopathy</th></tr><tr><th scope="row" class="infobox-label">Other names</th><td class="infobox-data">Portosystemic encephalopathy, hepatic coma,<sup id="cite_ref-NEJM2016_1-0" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> coma hepaticum</td></tr><tr style="background-color: #f8f9fa;"><td colspan="2" class="infobox-full-data"><span class="mw-default-size" typeof="mw:File/Frameless"><a href="/wiki/File:Alzheimer_type_II_astrocyte_high_mag.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/a/a0/Alzheimer_type_II_astrocyte_high_mag.jpg/220px-Alzheimer_type_II_astrocyte_high_mag.jpg" decoding="async" width="220" height="147" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/a/a0/Alzheimer_type_II_astrocyte_high_mag.jpg/330px-Alzheimer_type_II_astrocyte_high_mag.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/a/a0/Alzheimer_type_II_astrocyte_high_mag.jpg/440px-Alzheimer_type_II_astrocyte_high_mag.jpg 2x" data-file-width="4272" data-file-height="2848" /></a></span></td></tr><tr><td colspan="2" class="infobox-full-data"><a href="/wiki/Micrograph" title="Micrograph">Micrograph</a> of <a href="/wiki/Alzheimer_type_II_astrocyte" title="Alzheimer type II astrocyte">Alzheimer type II astrocytes</a>, as may be seen in hepatic encephalopathy</td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Medical_specialty" title="Medical specialty">Specialty</a></th><td class="infobox-data"><a href="/wiki/Gastroenterology" title="Gastroenterology">Gastroenterology</a></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Signs_and_symptoms" title="Signs and symptoms">Symptoms</a></th><td class="infobox-data"><a href="/wiki/Altered_level_of_consciousness" title="Altered level of consciousness">Altered level of consciousness</a>, mood changes, personality changes, movement problems<sup id="cite_ref-GARD2016_2-0" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> slurred speech, Sleep problems, Anxiety or irritability, Muscle twitches (myoclonus), Difficulty concentrating or short attention span, Flapping hand motion (asterixis), Reduced alertness, Cognitive impairment (confused thinking or judgment).<sup id="cite_ref-Hepatic_encephalopathy_3-0" class="reference"><a href="#cite_note-Hepatic_encephalopathy-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Complication_(medicine)" title="Complication (medicine)">Complications</a></th><td class="infobox-data">hepatic coma.<sup id="cite_ref-Hepatic_encephalopathy_3-1" class="reference"><a href="#cite_note-Hepatic_encephalopathy-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label">Types</th><td class="infobox-data">Acute, recurrent, persistent<sup id="cite_ref-Cash2010_4-0" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label">Causes</th><td class="infobox-data"><a href="/wiki/Liver_failure" title="Liver failure">Liver failure</a><sup id="cite_ref-GARD2016_2-1" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Risk_factor" title="Risk factor">Risk factors</a></th><td class="infobox-data"><a href="/wiki/Infections" class="mw-redirect" title="Infections">Infections</a>, <a href="/wiki/GI_bleeding" class="mw-redirect" title="GI bleeding">GI bleeding</a>, <a href="/wiki/Constipation" title="Constipation">constipation</a>, <a href="/wiki/Electrolyte_problems" class="mw-redirect" title="Electrolyte problems">electrolyte problems</a>, certain medications<sup id="cite_ref-AFP2011_5-0" class="reference"><a href="#cite_note-AFP2011-5"><span class="cite-bracket">[</span>5<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Medical_diagnosis" title="Medical diagnosis">Diagnostic method</a></th><td class="infobox-data">Based on symptoms after ruling out other possible causes<sup id="cite_ref-GARD2016_2-2" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Mer2019_6-0" class="reference"><a href="#cite_note-Mer2019-6"><span class="cite-bracket">[</span>6<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Differential_diagnosis" title="Differential diagnosis">Differential diagnosis</a></th><td class="infobox-data"><a href="/wiki/Wernicke%E2%80%93Korsakoff_syndrome" title="Wernicke–Korsakoff syndrome">Wernicke–Korsakoff syndrome</a>, <a href="/wiki/Delirium_tremens" title="Delirium tremens">delirium tremens</a>, <a href="/wiki/Hypoglycemia" title="Hypoglycemia">hypoglycemia</a>, <a href="/wiki/Subdural_hematoma" title="Subdural hematoma">subdural hematoma</a>, <a href="/wiki/Hyponatremia" title="Hyponatremia">hyponatremia</a><sup id="cite_ref-NEJM2016_1-1" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label">Treatment</th><td class="infobox-data"><a href="/wiki/Supportive_care" class="mw-redirect" title="Supportive care">Supportive care</a>, treating triggers, <a href="/wiki/Lactulose" title="Lactulose">lactulose</a>, <a href="/wiki/Liver_transplant" class="mw-redirect" title="Liver transplant">liver transplant</a><sup id="cite_ref-NEJM2016_1-2" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Cash2010_4-1" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label"><a href="/wiki/Prognosis" title="Prognosis">Prognosis</a></th><td class="infobox-data">Average <a href="/wiki/Life_expectancy" title="Life expectancy">life expectancy</a> less than a year in those with severe disease<sup id="cite_ref-NEJM2016_1-3" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup></td></tr><tr><th scope="row" class="infobox-label">Frequency</th><td class="infobox-data">Affects >40% with cirrhosis<sup id="cite_ref-Fer2018_7-0" class="reference"><a href="#cite_note-Fer2018-7"><span class="cite-bracket">[</span>7<span class="cite-bracket">]</span></a></sup></td></tr></tbody></table> <p><b>Hepatic encephalopathy</b> (<b>HE</b>) is an <a href="/wiki/Altered_level_of_consciousness" title="Altered level of consciousness">altered level of consciousness</a> as a result of <a href="/wiki/Liver_failure" title="Liver failure">liver failure</a>.<sup id="cite_ref-GARD2016_2-3" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> Its onset may be gradual or sudden.<sup id="cite_ref-GARD2016_2-4" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> Other symptoms may include movement problems, changes in <a href="/wiki/Mood_(psychology)" title="Mood (psychology)">mood</a>, or changes in <a href="/wiki/Personality" title="Personality">personality</a>.<sup id="cite_ref-GARD2016_2-5" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> In the advanced stages it can result in a <a href="/wiki/Coma" title="Coma">coma</a>.<sup id="cite_ref-Cash2010_4-2" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p><p>Hepatic encephalopathy can occur in those with acute or chronic liver disease.<sup id="cite_ref-Cash2010_4-3" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> Episodes can be triggered by <a href="/wiki/Infections" class="mw-redirect" title="Infections">infections</a>, <a href="/wiki/GI_bleeding" class="mw-redirect" title="GI bleeding">GI bleeding</a>, <a href="/wiki/Constipation" title="Constipation">constipation</a>, <a href="/wiki/Electrolyte_problems" class="mw-redirect" title="Electrolyte problems">electrolyte problems</a>, or certain medications.<sup id="cite_ref-AFP2011_5-1" class="reference"><a href="#cite_note-AFP2011-5"><span class="cite-bracket">[</span>5<span class="cite-bracket">]</span></a></sup> The underlying mechanism is believed to involve the buildup of <a href="/wiki/Ammonia" title="Ammonia">ammonia</a> in the blood, a substance that is normally removed by the <a href="/wiki/Liver" title="Liver">liver</a>.<sup id="cite_ref-GARD2016_2-6" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> The diagnosis is typically based on symptoms after ruling out other potential causes.<sup id="cite_ref-GARD2016_2-7" class="reference"><a href="#cite_note-GARD2016-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Mer2019_6-1" class="reference"><a href="#cite_note-Mer2019-6"><span class="cite-bracket">[</span>6<span class="cite-bracket">]</span></a></sup> It may be supported by blood ammonia levels, an <a href="/wiki/Electroencephalogram" class="mw-redirect" title="Electroencephalogram">electroencephalogram</a>, or a <a href="/wiki/CT_scan" title="CT scan">CT scan</a> of the brain.<sup id="cite_ref-Cash2010_4-4" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Mer2019_6-2" class="reference"><a href="#cite_note-Mer2019-6"><span class="cite-bracket">[</span>6<span class="cite-bracket">]</span></a></sup> </p><p>Hepatic encephalopathy is possibly reversible with treatment.<sup id="cite_ref-NEJM2016_1-4" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> This typically involves <a href="/wiki/Supportive_care" class="mw-redirect" title="Supportive care">supportive care</a> and addressing the triggers of the event.<sup id="cite_ref-Cash2010_4-5" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> <a href="/wiki/Lactulose" title="Lactulose">Lactulose</a> is frequently used to decrease ammonia levels.<sup id="cite_ref-NEJM2016_1-5" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> Certain <a href="/wiki/Antibiotics" class="mw-redirect" title="Antibiotics">antibiotics</a> (such as <a href="/wiki/Rifaximin" title="Rifaximin">rifaximin</a>) and <a href="/wiki/Probiotics" class="mw-redirect" title="Probiotics">probiotics</a> are other potential options.<sup id="cite_ref-NEJM2016_1-6" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> A <a href="/wiki/Liver_transplantation" title="Liver transplantation">liver transplant</a> may improve outcomes in those with severe disease.<sup id="cite_ref-NEJM2016_1-7" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> </p><p>More than 40% of people with <a href="/wiki/Cirrhosis" title="Cirrhosis">cirrhosis</a> develop hepatic encephalopathy.<sup id="cite_ref-Fer2018_7-1" class="reference"><a href="#cite_note-Fer2018-7"><span class="cite-bracket">[</span>7<span class="cite-bracket">]</span></a></sup> More than half of those with cirrhosis and significant HE live less than a year.<sup id="cite_ref-NEJM2016_1-8" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> In those who are able to get a liver transplant, the risk of death is less than 30% over the subsequent five years.<sup id="cite_ref-NEJM2016_1-9" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> The condition has been described since at least 1860.<sup id="cite_ref-NEJM2016_1-10" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> </p> <style data-mw-deduplicate="TemplateStyles:r886046785">.mw-parser-output .toclimit-2 .toclevel-1 ul,.mw-parser-output .toclimit-3 .toclevel-2 ul,.mw-parser-output .toclimit-4 .toclevel-3 ul,.mw-parser-output .toclimit-5 .toclevel-4 ul,.mw-parser-output .toclimit-6 .toclevel-5 ul,.mw-parser-output .toclimit-7 .toclevel-6 ul{display:none}</style><div class="toclimit-3"><meta property="mw:PageProp/toc" /></div> <div class="mw-heading mw-heading2"><h2 id="Signs_and_symptoms">Signs and symptoms</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=1" title="Edit section: Signs and symptoms"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The mildest form of hepatic encephalopathy is difficult to detect clinically, but may be demonstrated on <a href="/wiki/Neuropsychological_test" title="Neuropsychological test">neuropsychological testing</a>. It is experienced as forgetfulness, mild confusion, and irritability. The first stage of hepatic encephalopathy is characterised by an inverted sleep-wake pattern (sleeping by day, being awake at night). The second stage is marked by lethargy and personality changes. The third stage is marked by worsened confusion. The fourth stage is marked by a progression to coma.<sup id="cite_ref-Cash2010_4-6" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p><p>More severe forms of hepatic encephalopathy lead to a worsening level of consciousness, from lethargy to <a href="/wiki/Somnolence" title="Somnolence">somnolence</a> and eventually coma. In the intermediate stages, a characteristic jerking movement of the limbs is observed (<a href="/wiki/Asterixis" title="Asterixis">asterixis</a>, "liver flap" due to its flapping character); this disappears as the somnolence worsens. There is disorientation and amnesia, and uninhibited behaviour may occur. In the third stage, <a href="/wiki/Neurological_examination" title="Neurological examination">neurological examination</a> may reveal <a href="/wiki/Clonus" title="Clonus">clonus</a> and positive <a href="/wiki/Plantar_reflex" title="Plantar reflex">Babinski sign</a>. Coma and <a href="/wiki/Seizure" title="Seizure">seizures</a> represent the most advanced stage; <a href="/wiki/Cerebral_edema" title="Cerebral edema">cerebral edema</a> (swelling of the brain tissue) leads to death.<sup id="cite_ref-Cash2010_4-7" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p><p>Encephalopathy often occurs together with other symptoms and signs of liver failure. These may include <a href="/wiki/Jaundice" title="Jaundice">jaundice</a> (yellow discolouration of the skin and the whites of the eyes), <a href="/wiki/Ascites" title="Ascites">ascites</a> (fluid accumulation in the abdominal cavity), and <a href="/wiki/Peripheral_oedema" class="mw-redirect" title="Peripheral oedema">peripheral oedema</a> (swelling of the legs due to fluid build-up in the skin). The <a href="/wiki/Tendon_reflex" title="Tendon reflex">tendon reflexes</a> may be exaggerated, and the <a href="/wiki/Plantar_reflex" title="Plantar reflex">plantar reflex</a> may be abnormal, namely extending rather than flexing (Babinski's sign) in severe encephalopathy. A particular smell on an affected person's breath (<i><a href="/wiki/Fetor_hepaticus" title="Fetor hepaticus">foetor hepaticus</a></i>) may be detected.<sup id="cite_ref-ChungPodolsky_8-0" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Causes">Causes</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=2" title="Edit section: Causes"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>In a small proportion of cases, the encephalopathy is caused directly by liver failure; this is more likely in acute liver failure. More commonly, especially in chronic liver disease, hepatic encephalopathy is triggered by an additional cause, and identifying these triggers can be important to treat the episode effectively.<sup id="cite_ref-Cash2010_4-8" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p> <table class="wikitable" style="width:75%; margin-left:15px; text-align:center"> <tbody><tr> <th width="20%">Type </th> <th>Causes<sup id="cite_ref-Cash2010_4-9" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-1" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-0" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </th></tr> <tr> <th>Excessive<br />nitrogen load </th> <td align="left">Consumption of large amounts of <a href="/wiki/Protein" title="Protein">protein</a>, <a href="/wiki/Gastrointestinal_hemorrhage" class="mw-redirect" title="Gastrointestinal hemorrhage">gastrointestinal bleeding</a> e.g. from <a href="/wiki/Esophageal_varices" title="Esophageal varices">esophageal varices</a> (blood is high in protein, which is reabsorbed from the bowel), <a href="/wiki/Kidney_failure" title="Kidney failure">kidney failure</a> (inability to excrete nitrogen-containing waste products such as <a href="/wiki/Urea" title="Urea">urea</a>), <a href="/wiki/Constipation" title="Constipation">constipation</a> </td></tr> <tr> <th><a href="/wiki/Electrolyte_disturbance" class="mw-redirect" title="Electrolyte disturbance">Electrolyte or<br />metabolic disturbance</a> </th> <td align="left"><a href="/wiki/Hyponatraemia" class="mw-redirect" title="Hyponatraemia">Hyponatraemia</a> (low <a href="/wiki/Sodium" title="Sodium">sodium</a> level in the blood) and <a href="/wiki/Hypokalaemia" class="mw-redirect" title="Hypokalaemia">hypokalaemia</a> (low <a href="/wiki/Potassium" title="Potassium">potassium</a> levels)—these are both common in those taking <a href="/wiki/Diuretic" title="Diuretic">diuretics</a>, often used for the treatment of ascites; furthermore <a href="/wiki/Alkalosis" title="Alkalosis">alkalosis</a> (decreased acid level), <a href="/wiki/Hypoxia_(medical)" class="mw-redirect" title="Hypoxia (medical)">hypoxia</a> (insufficient oxygen levels), <a href="/wiki/Dehydration" title="Dehydration">dehydration</a> </td></tr> <tr> <th>Drugs and<br />medications </th> <td align="left"><a href="/wiki/Sedative" title="Sedative">Sedatives</a> such as <a href="/wiki/Benzodiazepine" title="Benzodiazepine">benzodiazepines</a> (often used to suppress <a href="/wiki/Alcohol_withdrawal_syndrome" title="Alcohol withdrawal syndrome">alcohol withdrawal</a> or <a href="/wiki/Anxiety_disorder" title="Anxiety disorder">anxiety disorder</a>), <a href="/wiki/Narcotic" title="Narcotic">narcotics</a> (used as <a href="/wiki/Analgesia" class="mw-redirect" title="Analgesia">painkillers</a> or drugs of abuse), <a href="/wiki/Antipsychotic" title="Antipsychotic">antipsychotics</a>, <a href="/wiki/Alcohol_intoxication" title="Alcohol intoxication">alcohol intoxication</a>, <a href="/wiki/Valproate" title="Valproate">Valproic Acid</a> (Used for Epilepsy, Bipolar Disorder, Anti-Migranal purposes. Extremely rare.)<sup id="cite_ref-10" class="reference"><a href="#cite_note-10"><span class="cite-bracket">[</span>10<span class="cite-bracket">]</span></a></sup> </td></tr> <tr> <th>Infection </th> <td align="left"><a href="/wiki/Pneumonia" title="Pneumonia">Pneumonia</a>, <a href="/wiki/Urinary_tract_infection" title="Urinary tract infection">urinary tract infection</a>, <a href="/wiki/Spontaneous_bacterial_peritonitis" title="Spontaneous bacterial peritonitis">spontaneous bacterial peritonitis</a>, other infections </td></tr> <tr> <th>Others </th> <td align="left"><a href="/wiki/Surgery" title="Surgery">Surgery</a>, progression of the liver disease, additional cause for liver damage (e.g. <a href="/wiki/Alcoholic_hepatitis" title="Alcoholic hepatitis">alcoholic hepatitis</a>, <a href="/wiki/Hepatitis_A" title="Hepatitis A">hepatitis A</a>) </td></tr> <tr> <th>Unknown </th> <td align="left">In 20–30% of cases, no clear cause for an attack can be found </td></tr></tbody></table> <p>Hepatic encephalopathy may also occur after the creation of a <a href="/wiki/Transjugular_intrahepatic_portosystemic_shunt" title="Transjugular intrahepatic portosystemic shunt">transjugular intrahepatic portosystemic shunt</a> (TIPS). This is used in the treatment of refractory <a href="/wiki/Ascites" title="Ascites">ascites</a>, bleeding from <a href="/wiki/Esophageal_varices" title="Esophageal varices">esophageal varices</a> and <a href="/wiki/Hepatorenal_syndrome" title="Hepatorenal syndrome">hepatorenal syndrome</a>.<sup id="cite_ref-11" class="reference"><a href="#cite_note-11"><span class="cite-bracket">[</span>11<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-12" class="reference"><a href="#cite_note-12"><span class="cite-bracket">[</span>12<span class="cite-bracket">]</span></a></sup> TIPS-related encephalopathy occurs in about 30% of cases, with the risk being higher in those with previous episodes of encephalopathy, higher age, female sex, and liver disease due to causes other than alcohol.<sup id="cite_ref-Sundaram_9-1" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Pathogenesis">Pathogenesis</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=3" title="Edit section: Pathogenesis"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <figure class="mw-default-size mw-halign-right" typeof="mw:File/Thumb"><a href="/wiki/File:Ammonia-3D-balls-A.png" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/0/05/Ammonia-3D-balls-A.png/220px-Ammonia-3D-balls-A.png" decoding="async" width="220" height="170" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/0/05/Ammonia-3D-balls-A.png/330px-Ammonia-3D-balls-A.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/0/05/Ammonia-3D-balls-A.png/440px-Ammonia-3D-balls-A.png 2x" data-file-width="1100" data-file-height="849" /></a><figcaption>Ball and stick model of ammonia; one nitrogen atom with three hydrogen atoms. Accumulation of <a href="/wiki/Ammonia" title="Ammonia">ammonia</a> in the bloodstream is associated with hepatic encephalopathy.</figcaption></figure> <p>There are various explanations why liver dysfunction or portosystemic shunting might lead to encephalopathy. In healthy subjects, <a href="/wiki/Nitrogen" title="Nitrogen">nitrogen</a>-containing compounds from the <a href="/wiki/Intestine" class="mw-redirect" title="Intestine">intestine</a>, generated by <a href="/wiki/Gut_flora" class="mw-redirect" title="Gut flora">gut bacteria</a> from food, are transported by the <a href="/wiki/Portal_vein" title="Portal vein">portal vein</a> to the liver, where 80–90% are <a href="/wiki/Metabolism" title="Metabolism">metabolised</a> through the <a href="/wiki/Urea_cycle" title="Urea cycle">urea cycle</a> and/or excreted immediately. This process is impaired in all subtypes of hepatic encephalopathy, either because the <a href="/wiki/Hepatocyte" title="Hepatocyte">hepatocytes</a> (liver cells) are incapable of metabolising the waste products or because portal venous blood bypasses the liver through <a href="/wiki/Collateral_circulation" title="Collateral circulation">collateral circulation</a> or a medically constructed shunt. Nitrogenous waste products accumulate in the <a href="/wiki/Systemic_circulation" class="mw-redirect" title="Systemic circulation">systemic circulation</a> (hence the older term "portosystemic encephalopathy"). The most important waste product is <a href="/wiki/Ammonia" title="Ammonia">ammonia</a> (NH<sub>3</sub>). This small molecule crosses the <a href="/wiki/Blood%E2%80%93brain_barrier" title="Blood–brain barrier">blood–brain barrier</a> and is absorbed and metabolised by the <a href="/wiki/Astrocyte" title="Astrocyte">astrocytes</a>, a population of cells in the brain that constitutes 30% of the <a href="/wiki/Cerebral_cortex" title="Cerebral cortex">cerebral cortex</a>. Astrocytes use ammonia when synthesising <a href="/wiki/Glutamine" title="Glutamine">glutamine</a> from <a href="/wiki/Glutamate" class="mw-redirect" title="Glutamate">glutamate</a>. The increased levels of glutamine lead to an increase in osmotic pressure in the astrocytes, which become swollen. There is increased activity of the inhibitory <a href="/wiki/Gamma-Aminobutyric_acid" class="mw-redirect" title="Gamma-Aminobutyric acid">γ-aminobutyric acid</a> (GABA) system and the energy supply to other brain cells is decreased. This can be thought of as an example of brain edema of the "cytotoxic" type.<sup id="cite_ref-13" class="reference"><a href="#cite_note-13"><span class="cite-bracket">[</span>13<span class="cite-bracket">]</span></a></sup> </p><p>Despite numerous studies demonstrating the central role of ammonia, ammonia levels do not always correlate with the severity of the encephalopathy; it is suspected that this means that more ammonia has already been absorbed into the brain in those with severe symptoms whose serum levels are relatively low.<sup id="cite_ref-Cash2010_4-10" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-2" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> Other waste products implicated in hepatic encephalopathy include <a href="/wiki/Mercaptan" class="mw-redirect" title="Mercaptan">mercaptans</a> (substances containing a thiol group), <a href="/wiki/Short-chain_fatty_acid" title="Short-chain fatty acid">short-chain fatty acids</a>, and <a href="/wiki/Phenol" title="Phenol">phenol</a>.<sup id="cite_ref-ChungPodolsky_8-3" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> </p><p>Numerous other abnormalities have been described in hepatic encephalopathy, although their relative contribution to the disease state is uncertain. Loss of glutamate transporter gene expression (especially EAAT 2) has been attributed to acute liver failure.<sup id="cite_ref-14" class="reference"><a href="#cite_note-14"><span class="cite-bracket">[</span>14<span class="cite-bracket">]</span></a></sup> <a href="/wiki/Benzodiazepine" title="Benzodiazepine">Benzodiazepine</a>-like compounds have been detected at increased levels as well as abnormalities in the GABA <a href="/wiki/Neurotransmitter" title="Neurotransmitter">neurotransmission system</a>. An imbalance between <a href="/wiki/Aromatic_amino_acids" class="mw-redirect" title="Aromatic amino acids">aromatic amino acids</a> (phenylalanine, tryptophan and tyrosine) and <a href="/wiki/Branched-chain_amino_acids" class="mw-redirect" title="Branched-chain amino acids">branched-chain amino acids</a> (leucine, isoleucine and valine) has been described; this would lead to the generation of <a href="/wiki/False_neurotransmitter" title="False neurotransmitter">false neurotransmitters</a> (such <a href="/wiki/Octopamine" title="Octopamine">octopamine</a> and <a href="/wiki/2-hydroxyphenethylamine" class="mw-redirect" title="2-hydroxyphenethylamine">2-hydroxyphenethylamine</a>). Dysregulation of the <a href="/wiki/Serotonin" title="Serotonin">serotonin</a> system, too, has been reported. Depletion of <a href="/wiki/Zinc" title="Zinc">zinc</a> and accumulation of <a href="/wiki/Manganese" title="Manganese">manganese</a> may play a role.<sup id="cite_ref-Cash2010_4-11" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-4" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> Inflammation elsewhere in the body may precipitate encephalopathy through the action of <a href="/wiki/Cytokine" title="Cytokine">cytokines</a> and bacterial <a href="/wiki/Lipopolysaccharide" title="Lipopolysaccharide">lipopolysaccharide</a> on astrocytes.<sup id="cite_ref-Sundaram_9-2" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Diagnosis">Diagnosis</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=4" title="Edit section: Diagnosis"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <figure class="mw-default-size mw-halign-right" typeof="mw:File/Thumb"><a href="/wiki/File:Alzheimer_type_II_astrocyte_high_mag_cropped.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/8/87/Alzheimer_type_II_astrocyte_high_mag_cropped.jpg/220px-Alzheimer_type_II_astrocyte_high_mag_cropped.jpg" decoding="async" width="220" height="326" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/8/87/Alzheimer_type_II_astrocyte_high_mag_cropped.jpg/330px-Alzheimer_type_II_astrocyte_high_mag_cropped.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/8/87/Alzheimer_type_II_astrocyte_high_mag_cropped.jpg/440px-Alzheimer_type_II_astrocyte_high_mag_cropped.jpg 2x" data-file-width="1116" data-file-height="1652" /></a><figcaption><a href="/wiki/Micrograph" title="Micrograph">Micrograph</a> of <a href="/wiki/Alzheimer_type_II_astrocyte" title="Alzheimer type II astrocyte">Alzheimer type II astrocytes</a>, as may be seen in hepatic encephalopathy</figcaption></figure> <div class="mw-heading mw-heading3"><h3 id="Investigations">Investigations</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=5" title="Edit section: Investigations"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The diagnosis of hepatic encephalopathy can only be made in the presence of confirmed liver disease (types A and C) or a portosystemic shunt (type B), as its symptoms are similar to those encountered in other <a href="/wiki/Encephalopathy" title="Encephalopathy">encephalopathies</a>. To make the distinction, abnormal <a href="/wiki/Liver_function_tests" title="Liver function tests">liver function tests</a> and/or <a href="/wiki/Medical_ultrasonography" class="mw-redirect" title="Medical ultrasonography">ultrasound</a> suggesting liver disease are required, and ideally a <a href="/wiki/Liver_biopsy" title="Liver biopsy">liver biopsy</a>.<sup id="cite_ref-Cash2010_4-12" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-5" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> The symptoms of hepatic encephalopathy may also arise from other conditions, such as <a href="/wiki/Cerebral_haemorrhage" class="mw-redirect" title="Cerebral haemorrhage">bleeding in the brain</a> and <a href="/wiki/Seizure" title="Seizure">seizures</a> (both of which are more common in chronic liver disease). A <a href="/wiki/Computed_tomography" class="mw-redirect" title="Computed tomography">CT scan</a> of the brain may be required to exclude bleeding in the brain, and if seizure activity is suspected an <a href="/wiki/Electroencephalography" title="Electroencephalography">electroencephalograph</a> (EEG) study may be performed.<sup id="cite_ref-Cash2010_4-13" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> Rarer mimics of encephalopathy are <a href="/wiki/Meningitis" title="Meningitis">meningitis</a>, <a href="/wiki/Encephalitis" title="Encephalitis">encephalitis</a>, <a href="/wiki/Wernicke%27s_encephalopathy" class="mw-redirect" title="Wernicke's encephalopathy">Wernicke's encephalopathy</a> and <a href="/wiki/Wilson%27s_disease" title="Wilson's disease">Wilson's disease</a>; these may be suspected on clinical grounds and confirmed with investigations.<sup id="cite_ref-ChungPodolsky_8-6" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Ferenci_15-0" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> </p><p>The diagnosis of hepatic encephalopathy is a clinical one, once other causes for confusion or coma have been excluded; no test fully diagnoses or excludes it. Serum ammonia levels are elevated in 90% of people, but not all <a href="/wiki/Hyperammonaemia" class="mw-redirect" title="Hyperammonaemia">hyperammonaemia</a> (high ammonia levels in the blood) is associated with encephalopathy.<sup id="cite_ref-Cash2010_4-14" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-7" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> A CT scan of the brain usually shows no abnormality except in stage IV encephalopathy, when brain swelling (cerebral oedema) may be visible.<sup id="cite_ref-ChungPodolsky_8-8" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> Other <a href="/wiki/Neuroimaging" title="Neuroimaging">neuroimaging</a> modalities, such as <a href="/wiki/Magnetic_resonance_imaging" title="Magnetic resonance imaging">magnetic resonance imaging</a> (MRI), are not currently regarded as useful, although they may show abnormalities.<sup id="cite_ref-Ferenci_15-1" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> Electroencephalography shows no clear abnormalities in stage 0, even if minimal HE is present; in stages I, II and III there are triphasic waves over the <a href="/wiki/Frontal_lobe" title="Frontal lobe">frontal lobes</a> that oscillate at 5 Hz, and in stage IV there is slow <a href="/wiki/Delta_wave" title="Delta wave">delta wave</a> activity.<sup id="cite_ref-Cash2010_4-15" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> However, the changes in EEG are not typical enough to be useful in distinguishing hepatic encephalopathy from other conditions.<sup id="cite_ref-Ferenci_15-2" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> </p><p>Once the diagnosis of encephalopathy has been made, efforts are made to exclude underlying causes (such as listed above in "<a href="#Causes">causes</a>"). This requires <a href="/wiki/Blood_test" title="Blood test">blood tests</a> (urea and electrolytes, full blood count, liver function tests), usually a <a href="/wiki/Chest_X-ray" class="mw-redirect" title="Chest X-ray">chest X-ray</a>, and <a href="/wiki/Urinalysis" title="Urinalysis">urinalysis</a>. If there is ascites, a diagnostic <a href="/wiki/Paracentesis" title="Paracentesis">paracentesis</a> (removal of a fluid sample with a needle) may be required to identify <a href="/wiki/Spontaneous_bacterial_peritonitis" title="Spontaneous bacterial peritonitis">spontaneous bacterial peritonitis</a> (SBP).<sup id="cite_ref-Cash2010_4-16" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Classification">Classification</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=6" title="Edit section: Classification"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <div class="mw-heading mw-heading4"><h4 id="West_Haven_criteria">West Haven criteria</h4><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=7" title="Edit section: West Haven criteria"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The severity of hepatic encephalopathy is graded with the West Haven Criteria; this is based on the level of impairment of autonomy, changes in consciousness, intellectual function, behavior, and dependence on therapy.<sup id="cite_ref-Cash2010_4-17" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-16" class="reference"><a href="#cite_note-16"><span class="cite-bracket">[</span>16<span class="cite-bracket">]</span></a></sup> </p> <ul><li>Grade 0 - No obvious changes other than a potentially mild decrease in intellectual ability and coordination</li> <li>Grade 1 - Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction</li> <li>Grade 2 - Lethargy or <a href="/wiki/Apathy" title="Apathy">apathy</a>; minimal disorientation for time or place; subtle personality change; inappropriate behaviour</li> <li>Grade 3 - <a href="/wiki/Somnolence" title="Somnolence">Somnolence</a> to semi<a href="/wiki/Stupor" title="Stupor">stupor</a>, but responsive to verbal stimuli; confusion; gross disorientation</li> <li>Grade 4 - <a href="/wiki/Coma" title="Coma">Coma</a></li></ul> <div class="mw-heading mw-heading4"><h4 id="Types">Types</h4><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=8" title="Edit section: Types"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <figure class="mw-default-size mw-halign-right" typeof="mw:File/Thumb"><a href="/wiki/File:Cirrhosis_high_mag.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/9/94/Cirrhosis_high_mag.jpg/220px-Cirrhosis_high_mag.jpg" decoding="async" width="220" height="147" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/9/94/Cirrhosis_high_mag.jpg/330px-Cirrhosis_high_mag.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/94/Cirrhosis_high_mag.jpg/440px-Cirrhosis_high_mag.jpg 2x" data-file-width="4272" data-file-height="2848" /></a><figcaption><a href="/wiki/Micrograph" title="Micrograph">Micrograph</a> showing liver <a href="/wiki/Cirrhosis" title="Cirrhosis">cirrhosis</a>, a condition that often precedes hepatic encephalopathy. <a href="/wiki/Trichrome_stain" class="mw-redirect" title="Trichrome stain">Trichrome stain</a>.</figcaption></figure> <p>A classification of hepatic encephalopathy was introduced at the World Congress of <a href="/wiki/Gastroenterology" title="Gastroenterology">Gastroenterology</a> 1998 in Vienna. According to this classification, hepatic encephalopathy is subdivided in type A, B and C depending on the underlying cause.<sup id="cite_ref-Ferenci_15-3" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> </p> <ul><li><i>Type A (=acute)</i> describes hepatic encephalopathy associated with <a href="/wiki/Acute_liver_failure" title="Acute liver failure">acute liver failure</a>, typically associated with <a href="/wiki/Cerebral_oedema" class="mw-redirect" title="Cerebral oedema">cerebral oedema</a></li> <li><i>Type B (=<a href="/wiki/Bypass_(surgical)" class="mw-redirect" title="Bypass (surgical)">bypass</a>)</i> is caused by portal-systemic shunting without associated intrinsic liver disease</li> <li><i>Type C (=<a href="/wiki/Cirrhosis" title="Cirrhosis">cirrhosis</a></i>) occurs in people with cirrhosis - this type is subdivided in <i>episodic</i>, <i>persistent</i> and <i>minimal</i> encephalopathy</li></ul> <p>The term <i>minimal encephalopathy</i> (MHE) is defined as encephalopathy that does not lead to clinically overt cognitive dysfunction, but can be demonstrated with neuropsychological studies.<sup id="cite_ref-Ferenci_15-4" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Randolph_17-0" class="reference"><a href="#cite_note-Randolph-17"><span class="cite-bracket">[</span>17<span class="cite-bracket">]</span></a></sup> This is still an important finding, as minimal encephalopathy has been demonstrated to impair <a href="/wiki/Quality_of_life" title="Quality of life">quality of life</a> and increase the risk of involvement in <a href="/wiki/Traffic_collision" title="Traffic collision">road traffic accidents</a>.<sup id="cite_ref-Bajaj_18-0" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading4"><h4 id="Minimal_HE">Minimal HE</h4><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=9" title="Edit section: Minimal HE"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The diagnosis of minimal hepatic encephalopathy requires neuropsychological testing by definition. Older tests include the "numbers connecting test" A and B (measuring the speed at which one could connect randomly dispersed numbers 1–20), the "block design test" and the "digit-symbol test".<sup id="cite_ref-Ferenci_15-5" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> In 2009 an expert panel concluded that neuropsychological test batteries aimed at measuring multiple domains of cognitive function are generally more reliable than single tests, and tend to be more strongly correlated with functional status. Both the <a href="/wiki/Repeatable_Battery_for_the_Assessment_of_Neuropsychological_Status" title="Repeatable Battery for the Assessment of Neuropsychological Status">Repeatable Battery for the Assessment of Neuropsychological Status</a> (RBANS)<sup id="cite_ref-19" class="reference"><a href="#cite_note-19"><span class="cite-bracket">[</span>19<span class="cite-bracket">]</span></a></sup> and PSE-Syndrom-Test<sup id="cite_ref-Weissenborn_20-0" class="reference"><a href="#cite_note-Weissenborn-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup> may be used for this purpose.<sup id="cite_ref-Randolph_17-1" class="reference"><a href="#cite_note-Randolph-17"><span class="cite-bracket">[</span>17<span class="cite-bracket">]</span></a></sup> The PSE-Syndrom-Test, developed in Germany and validated in several other European countries, incorporates older assessment tools such as the number connection test.<sup id="cite_ref-Ferenci_15-6" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Randolph_17-2" class="reference"><a href="#cite_note-Randolph-17"><span class="cite-bracket">[</span>17<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Bajaj_18-1" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Weissenborn_20-1" class="reference"><a href="#cite_note-Weissenborn-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Treatment">Treatment</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=10" title="Edit section: Treatment"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Those with severe encephalopathy (stages 3 and 4) are at risk of obstructing their <a href="/wiki/Airway" class="mw-redirect" title="Airway">airway</a> due to decreased protective reflexes such as the <a href="/wiki/Gag_reflex" class="mw-redirect" title="Gag reflex">gag reflex</a>. This can lead to <a href="/wiki/Respiratory_arrest" title="Respiratory arrest">respiratory arrest</a>. Transferring the person to a higher level of nursing care, such as an <a href="/wiki/Intensive_care_unit" title="Intensive care unit">intensive care unit</a>, is required, and <a href="/wiki/Intubation" title="Intubation">intubation</a> of the airway is often necessary to prevent life-threatening complications (e.g., aspiration or respiratory failure).<sup id="cite_ref-ChungPodolsky_8-9" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Polson_21-0" class="reference"><a href="#cite_note-Polson-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup> Placement of a <a href="/wiki/Nasogastric_intubation" class="mw-redirect" title="Nasogastric intubation">nasogastric tube</a> permits the safe administration of nutrients and medication.<sup id="cite_ref-Cash2010_4-18" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p><p>The treatment of hepatic encephalopathy depends on the suspected underlying cause (types A, B, or C) and the presence or absence of underlying causes. If encephalopathy develops in acute liver failure (type A), even in a mild form (grade 1–2), it indicates that a liver transplant may be required, and transfer to a specialist centre is advised.<sup id="cite_ref-Polson_21-1" class="reference"><a href="#cite_note-Polson-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup> Hepatic encephalopathy type B may arise in those who have undergone a TIPS procedure; in most cases this resolves spontaneously or with the medical treatments discussed below, but in a small proportion of about 5%, <a href="/wiki/Vascular_occlusion" title="Vascular occlusion">occlusion</a> of the shunt is required to address the symptoms.<sup id="cite_ref-Sundaram_9-3" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p><p>In hepatic encephalopathy type C, the identification and treatment of alternative or underlying causes is central to the initial management.<sup id="cite_ref-Cash2010_4-19" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-10" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-4" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Bajaj_18-2" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> Given the frequency of infection as the underlying cause, antibiotics are often administered <a href="/wiki/Empiric_therapy" title="Empiric therapy">empirically</a> (without knowledge of the exact source and nature of the infection).<sup id="cite_ref-Cash2010_4-20" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-5" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> Once an episode of encephalopathy has been effectively treated, a decision may need to be made on whether to prepare for a liver transplant.<sup id="cite_ref-Bajaj_18-3" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Diet">Diet</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=11" title="Edit section: Diet"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>In the past, it was thought that consumption of protein even at normal levels increased the risk of hepatic encephalopathy. This has been shown to be incorrect. Furthermore, many people with chronic liver disease are malnourished and require adequate protein to maintain a stable body weight. A diet with adequate protein and energy is therefore recommended.<sup id="cite_ref-Cash2010_4-21" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-6" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p><p>Dietary supplementation with <a href="/wiki/Branched-chain_amino_acid" title="Branched-chain amino acid">branched-chain amino acids</a> has shown improvement of encephalopathy and other complications of cirrhosis.<sup id="cite_ref-Cash2010_4-22" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-7" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p><p>Some studies have shown benefit of administration of <a href="/wiki/Probiotic" title="Probiotic">probiotics</a> ("healthy bacteria").<sup id="cite_ref-Sundaram_9-8" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Lactulose/lactitol"><span id="Lactulose.2Flactitol"></span>Lactulose/lactitol</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=12" title="Edit section: Lactulose/lactitol"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p><a href="/wiki/Lactulose" title="Lactulose">Lactulose</a> and <a href="/wiki/Lactitol" title="Lactitol">lactitol</a> are <a href="/wiki/Disaccharide" title="Disaccharide">disaccharides</a> that are not absorbed from the digestive tract. They are thought to decrease the generation of ammonia by bacteria, render the ammonia inabsorbable by converting it to ammonium (NH<sub>4</sub><sup>+</sup>) ions, and increase transit of bowel content through the gut. Doses of 15-30 mL are typically administered three times a day; the result is aimed to be 3–5 soft stools a day, or (in some settings) a stool <a href="/wiki/PH" title="PH">pH</a> of <6.0.<sup id="cite_ref-Cash2010_4-23" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ChungPodolsky_8-11" class="reference"><a href="#cite_note-ChungPodolsky-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Sundaram_9-9" class="reference"><a href="#cite_note-Sundaram-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Bajaj_18-4" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> Lactulose may also be given by <a href="/wiki/Enema" title="Enema">enema</a>, especially if encephalopathy is severe.<sup id="cite_ref-Bajaj_18-5" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> More commonly, <a href="/wiki/Sodium_phosphate" title="Sodium phosphate">phosphate</a> enemas are used. This may relieve constipation, one of the causes of encephalopathy, and increase bowel transit.<sup id="cite_ref-Cash2010_4-24" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p><p>Lactulose and lactitol are beneficial for treating hepatic encephalopathy, and are the recommended first-line treatment.<sup id="cite_ref-Cash2010_4-25" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-:0_22-0" class="reference"><a href="#cite_note-:0-22"><span class="cite-bracket">[</span>22<span class="cite-bracket">]</span></a></sup> Lactulose does not appear to be more effective than lactitol for treating people with hepatic encephalopathy.<sup id="cite_ref-:0_22-1" class="reference"><a href="#cite_note-:0-22"><span class="cite-bracket">[</span>22<span class="cite-bracket">]</span></a></sup> Side effects of lactulose and lactitol include the possibility of <a href="/wiki/Diarrhea" title="Diarrhea">diarrhea</a>, <a href="/wiki/Abdominal_bloating" class="mw-redirect" title="Abdominal bloating">abdominal bloating</a>, <a href="/wiki/Flatulence" title="Flatulence">gassiness</a>, and <a href="/wiki/Nausea" title="Nausea">nausea</a>.<sup id="cite_ref-:0_22-2" class="reference"><a href="#cite_note-:0-22"><span class="cite-bracket">[</span>22<span class="cite-bracket">]</span></a></sup> In acute liver failure, it is unclear whether lactulose is beneficial. The possible side effect of bloating may interfere with a liver transplant procedure if required.<sup id="cite_ref-Polson_21-2" class="reference"><a href="#cite_note-Polson-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Antibiotics">Antibiotics</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=13" title="Edit section: Antibiotics"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The antibiotic <a href="/wiki/Rifaximin" title="Rifaximin">rifaximin</a> may be recommended in addition to lactulose for those with recurrent disease.<sup id="cite_ref-NEJM2016_1-11" class="reference"><a href="#cite_note-NEJM2016-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> It is a nonabsorbable antibiotic from the <a href="/wiki/Rifamycin" title="Rifamycin">rifamycin</a> class. This is thought to work in a similar way to other antibiotics but without the complications attached to <a href="/wiki/Neomycin" title="Neomycin">neomycin</a> or <a href="/wiki/Metronidazole" title="Metronidazole">metronidazole</a>. Due to the long history and lower cost of lactulose use, rifaximin is generally only used as a second-line treatment if lactulose is poorly tolerated or not effective. When rifaximin is added to lactulose, the combination of the two may be more effective than each component separately.<sup id="cite_ref-Cash2010_4-26" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> Rifaximin is more expensive than lactulose, but the cost may be offset by fewer hospital admissions for encephalopathy.<sup id="cite_ref-Bajaj_18-6" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> </p><p>The antibiotics neomycin and metronidazole are other antibiotics used to treat hepatic encephalopathy.<sup id="cite_ref-23" class="reference"><a href="#cite_note-23"><span class="cite-bracket">[</span>23<span class="cite-bracket">]</span></a></sup> The rationale of their use was the fact that ammonia and other waste products are generated and converted by intestinal bacteria, and killing these bacteria would reduce the generation of these waste products. Neomycin was chosen because of its <a href="/wiki/Bioavailability" title="Bioavailability">low intestinal absorption</a>, as neomycin and similar <a href="/wiki/Aminoglycoside" title="Aminoglycoside">aminoglycoside</a> antibiotics may cause <a href="/wiki/Hearing_loss" title="Hearing loss">hearing loss</a> and <a href="/wiki/Kidney_failure" title="Kidney failure">kidney failure</a> if used <a href="/wiki/Parenterally" class="mw-redirect" title="Parenterally">by injection</a>. Later studies showed that neomycin was indeed absorbed <a href="/wiki/Route_of_administration" title="Route of administration">when taken by mouth</a>, with resultant complications. Metronidazole, similarly, is less commonly used because prolonged use can cause <a href="/wiki/Peripheral_neuropathy" title="Peripheral neuropathy">nerve damage</a>, in addition to gastrointestinal side effects.<sup id="cite_ref-Cash2010_4-27" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="L-Ornithine_and_L-aspartate"><small>L</small>-Ornithine and <small>L</small>-aspartate</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=14" title="Edit section: L-Ornithine and L-aspartate"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The combination of <a href="/wiki/Ornithine" title="Ornithine"><small>L</small>-ornithine</a> and <a href="/wiki/Aspartic_acid" title="Aspartic acid"><small>L</small>-aspartate</a> (LOLA) lowers the level of ammonia in a person's blood.<sup id="cite_ref-Goh2018_24-0" class="reference"><a href="#cite_note-Goh2018-24"><span class="cite-bracket">[</span>24<span class="cite-bracket">]</span></a></sup> Very weak evidence from clinical trials indicates that LOLA treatment may benefit people with hepatic encephalopathy.<sup id="cite_ref-Goh2018_24-1" class="reference"><a href="#cite_note-Goh2018-24"><span class="cite-bracket">[</span>24<span class="cite-bracket">]</span></a></sup> LOLA lowers ammonia levels by increasing the generation of <a href="/wiki/Urea" title="Urea">urea</a> through the <a href="/wiki/Urea_cycle" title="Urea cycle">urea cycle</a>, a <a href="/wiki/Metabolic_pathway" title="Metabolic pathway">metabolic pathway</a> that removes ammonia by turning it into the neutral substance urea.<sup id="cite_ref-25" class="reference"><a href="#cite_note-25"><span class="cite-bracket">[</span>25<span class="cite-bracket">]</span></a></sup> LOLA may be combined with lactulose and/or rifaximin if these alone are ineffective at controlling symptoms.<sup id="cite_ref-Cash2010_4-28" class="reference"><a href="#cite_note-Cash2010-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Epidemiology_and_prognosis">Epidemiology and prognosis</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=15" title="Edit section: Epidemiology and prognosis"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>In those with cirrhosis, the risk of developing hepatic encephalopathy is 20% per year, and at any time about 30–45% of people with cirrhosis exhibit evidence of overt encephalopathy. The prevalence of minimal hepatic encephalopathy detectable on formal neuropsychological testing is 60–80%; this increases the likelihood of developing overt encephalopathy in the future.<sup id="cite_ref-Bajaj_18-7" class="reference"><a href="#cite_note-Bajaj-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> Once hepatic encephalopathy has developed, the <a href="/wiki/Prognosis" title="Prognosis">prognosis</a> is determined largely by other markers of liver failure, such as the levels of <a href="/wiki/Albumin" title="Albumin">albumin</a> (a protein produced by the liver), the <a href="/wiki/Prothrombin_time" title="Prothrombin time">prothrombin time</a> (a test of <a href="/wiki/Coagulation" title="Coagulation">coagulation</a>, which relies on proteins produced in the liver), the presence of <a href="/wiki/Ascites" title="Ascites">ascites</a> and the level of <a href="/wiki/Bilirubin" title="Bilirubin">bilirubin</a> (a breakdown product of <a href="/wiki/Hemoglobin" title="Hemoglobin">hemoglobin</a> which is conjugated and excreted by the liver). Together with the severity of encephalopathy, these markers have been incorporated into the <a href="/wiki/Child%E2%80%93Pugh_score" title="Child–Pugh score">Child–Pugh score</a>; this score determines the one- and two-year survival and may assist in a decision to offer liver transplantation.<sup id="cite_ref-Ferenci_15-7" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> </p><p>In acute liver failure, the development of severe encephalopathy strongly predicts short-term mortality and is almost as important as the nature of the underlying cause of the liver failure in determining the prognosis. Historically, widely used criteria for offering liver transplantation, such as <a href="/wiki/King%27s_College_Criteria" title="King's College Criteria">King's College Criteria</a>, are of limited use and recent guidelines discourage excessive reliance on these criteria. The occurrence of hepatic encephalopathy in people with Wilson's disease (hereditary copper accumulation) and mushroom poisoning indicates an urgent need for a liver transplant.<sup id="cite_ref-Polson_21-3" class="reference"><a href="#cite_note-Polson-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="History">History</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=16" title="Edit section: History"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The occurrence of disturbed behaviour in people with jaundice may have been described in antiquity by <a href="/wiki/Hippocrates" title="Hippocrates">Hippocrates of Cos</a> (<abbr title="circa">c.</abbr><span style="white-space:nowrap;"> 460</span>–370 BCE).<sup id="cite_ref-Weissenborn_20-2" class="reference"><a href="#cite_note-Weissenborn-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Summerskill_26-0" class="reference"><a href="#cite_note-Summerskill-26"><span class="cite-bracket">[</span>26<span class="cite-bracket">]</span></a></sup> <a href="/wiki/Aulus_Cornelius_Celsus" title="Aulus Cornelius Celsus">Celsus</a> and <a href="/wiki/Galen" title="Galen">Galen</a> (first and third century respectively) both recognised the condition. Many modern descriptions of the link between liver disease and neuropsychiatric symptoms were made in the eighteenth and nineteenth century; for instance, <a href="/wiki/Giovanni_Battista_Morgagni" title="Giovanni Battista Morgagni">Giovanni Battista Morgagni</a> (1682–1771) reported in 1761 that it was a progressive condition.<sup id="cite_ref-Summerskill_26-1" class="reference"><a href="#cite_note-Summerskill-26"><span class="cite-bracket">[</span>26<span class="cite-bracket">]</span></a></sup> </p><p>In the 1950s, several reports enumerated the numerous abnormalities reported previously, and confirmed the previously enunciated theory that metabolic impairment and portosystemic shunting are the underlying mechanisms behind hepatic encephalopathy, and that the nitrogen-rich compounds originate from the intestine.<sup id="cite_ref-Weissenborn_20-3" class="reference"><a href="#cite_note-Weissenborn-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-27" class="reference"><a href="#cite_note-27"><span class="cite-bracket">[</span>27<span class="cite-bracket">]</span></a></sup> Professor Dame <a href="/wiki/Sheila_Sherlock" title="Sheila Sherlock">Sheila Sherlock</a> (1918–2001) performed many of these studies at the <a href="/wiki/Royal_Postgraduate_Medical_School" title="Royal Postgraduate Medical School">Royal Postgraduate Medical School</a> in <a href="/wiki/London" title="London">London</a> and subsequently at the <a href="/wiki/Royal_Free_Hospital" title="Royal Free Hospital">Royal Free Hospital</a>. The same group investigated protein restriction<sup id="cite_ref-Summerskill_26-2" class="reference"><a href="#cite_note-Summerskill-26"><span class="cite-bracket">[</span>26<span class="cite-bracket">]</span></a></sup> and neomycin.<sup id="cite_ref-28" class="reference"><a href="#cite_note-28"><span class="cite-bracket">[</span>28<span class="cite-bracket">]</span></a></sup> </p><p>The <a href="/wiki/West_Haven,_Connecticut" title="West Haven, Connecticut">West Haven</a> classification was formulated by Professor Harold Conn (1925–2011) and colleagues at <a href="/wiki/Yale_University" title="Yale University">Yale University</a> while investigating the therapeutic efficacy of lactulose.<sup id="cite_ref-Ferenci_15-8" class="reference"><a href="#cite_note-Ferenci-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Conn_29-0" class="reference"><a href="#cite_note-Conn-29"><span class="cite-bracket">[</span>29<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Boyer_30-0" class="reference"><a href="#cite_note-Boyer-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="References">References</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Hepatic_encephalopathy&action=edit&section=17" title="Edit section: References"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <style data-mw-deduplicate="TemplateStyles:r1239543626">.mw-parser-output .reflist{margin-bottom:0.5em;list-style-type:decimal}@media screen{.mw-parser-output .reflist{font-size:90%}}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}</style><div class="reflist"> <div class="mw-references-wrap mw-references-columns"><ol class="references"> <li id="cite_note-NEJM2016-1"><span class="mw-cite-backlink">^ <a href="#cite_ref-NEJM2016_1-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-3"><sup><i><b>d</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-4"><sup><i><b>e</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-5"><sup><i><b>f</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-6"><sup><i><b>g</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-7"><sup><i><b>h</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-8"><sup><i><b>i</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-9"><sup><i><b>j</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-10"><sup><i><b>k</b></i></sup></a> <a href="#cite_ref-NEJM2016_1-11"><sup><i><b>l</b></i></sup></a></span> <span class="reference-text"><style data-mw-deduplicate="TemplateStyles:r1238218222">.mw-parser-output cite.citation{font-style:inherit;word-wrap:break-word}.mw-parser-output .citation q{quotes:"\"""\"""'""'"}.mw-parser-output .citation:target{background-color:rgba(0,127,255,0.133)}.mw-parser-output .id-lock-free.id-lock-free a{background:url("//upload.wikimedia.org/wikipedia/commons/6/65/Lock-green.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-limited.id-lock-limited a,.mw-parser-output .id-lock-registration.id-lock-registration a{background:url("//upload.wikimedia.org/wikipedia/commons/d/d6/Lock-gray-alt-2.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-subscription.id-lock-subscription a{background:url("//upload.wikimedia.org/wikipedia/commons/a/aa/Lock-red-alt-2.svg")right 0.1em center/9px no-repeat}.mw-parser-output .cs1-ws-icon a{background:url("//upload.wikimedia.org/wikipedia/commons/4/4c/Wikisource-logo.svg")right 0.1em center/12px no-repeat}body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-free a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-limited a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-registration a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-subscription a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .cs1-ws-icon a{background-size:contain;padding:0 1em 0 0}.mw-parser-output .cs1-code{color:inherit;background:inherit;border:none;padding:inherit}.mw-parser-output .cs1-hidden-error{display:none;color:var(--color-error,#d33)}.mw-parser-output .cs1-visible-error{color:var(--color-error,#d33)}.mw-parser-output .cs1-maint{display:none;color:#085;margin-left:0.3em}.mw-parser-output .cs1-kern-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right{padding-right:0.2em}.mw-parser-output .citation .mw-selflink{font-weight:inherit}@media screen{.mw-parser-output .cs1-format{font-size:95%}html.skin-theme-clientpref-night .mw-parser-output .cs1-maint{color:#18911f}}@media screen and (prefers-color-scheme:dark){html.skin-theme-clientpref-os .mw-parser-output .cs1-maint{color:#18911f}}</style><cite id="CITEREFWijdicks2016" class="citation journal cs1">Wijdicks, EF (27 October 2016). "Hepatic Encephalopathy". <i>The New England Journal of Medicine</i>. <b>375</b> (17): 1660–1670. <a href="/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1056%2FNEJMra1600561">10.1056/NEJMra1600561</a>. <a href="/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/27783916">27783916</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=The+New+England+Journal+of+Medicine&rft.atitle=Hepatic+Encephalopathy.&rft.volume=375&rft.issue=17&rft.pages=1660-1670&rft.date=2016-10-27&rft_id=info%3Adoi%2F10.1056%2FNEJMra1600561&rft_id=info%3Apmid%2F27783916&rft.aulast=Wijdicks&rft.aufirst=EF&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHepatic+encephalopathy" class="Z3988"></span></span> </li> <li id="cite_note-GARD2016-2"><span class="mw-cite-backlink">^ <a href="#cite_ref-GARD2016_2-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-GARD2016_2-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-GARD2016_2-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-GARD2016_2-3"><sup><i><b>d</b></i></sup></a> <a href="#cite_ref-GARD2016_2-4"><sup><i><b>e</b></i></sup></a> <a href="#cite_ref-GARD2016_2-5"><sup><i><b>f</b></i></sup></a> <a href="#cite_ref-GARD2016_2-6"><sup><i><b>g</b></i></sup></a> <a href="#cite_ref-GARD2016_2-7"><sup><i><b>h</b></i></sup></a></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1238218222"><cite class="citation web cs1"><a rel="nofollow" class="external text" href="https://rarediseases.info.nih.gov/diseases/10452/hepatic-encephalopathy">"Hepatic encephalopathy"</a>. <i>GARD</i>. 2016. <a rel="nofollow" class="external text" href="https://web.archive.org/web/20170705031053/https://rarediseases.info.nih.gov/diseases/10452/hepatic-encephalopathy">Archived</a> from the original on 5 July 2017<span class="reference-accessdate">. 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Med</i>. <b>262</b> (8): 385–9. <a href="/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1056%2FNEJM196002252620803">10.1056/NEJM196002252620803</a>. <a href="/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/14414396">14414396</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=N.+Engl.+J.+Med.&rft.atitle=Systemic+absorption+of+orally+administered+neomycin+in+liver+disease&rft.volume=262&rft.issue=8&rft.pages=385-9&rft.date=1960-02&rft_id=info%3Adoi%2F10.1056%2FNEJM196002252620803&rft_id=info%3Apmid%2F14414396&rft.aulast=Last&rft.aufirst=PM&rft.au=Sherlock%2C+S&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHepatic+encephalopathy" class="Z3988"></span></span> </li> <li id="cite_note-Conn-29"><span class="mw-cite-backlink"><b><a href="#cite_ref-Conn_29-0">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1238218222"><cite id="CITEREFConnLeevyVlahcevic1977" class="citation journal cs1">Conn HO, Leevy CM, Vlahcevic ZR, et al. (1977). <a rel="nofollow" class="external text" href="https://doi.org/10.1016%2FS0016-5085%2877%2980135-2">"Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial"</a>. <i>Gastroenterology</i>. <b>72</b> (4 Pt 1): 573–83. <a href="/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://doi.org/10.1016%2FS0016-5085%2877%2980135-2">10.1016/S0016-5085(77)80135-2</a></span>. <a href="/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/14049">14049</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Gastroenterology&rft.atitle=Comparison+of+lactulose+and+neomycin+in+the+treatment+of+chronic+portal-systemic+encephalopathy.+A+double+blind+controlled+trial&rft.volume=72&rft.issue=4+Pt+1&rft.pages=573-83&rft.date=1977&rft_id=info%3Adoi%2F10.1016%2FS0016-5085%2877%2980135-2&rft_id=info%3Apmid%2F14049&rft.aulast=Conn&rft.aufirst=HO&rft.au=Leevy%2C+CM&rft.au=Vlahcevic%2C+ZR&rft_id=https%3A%2F%2Fdoi.org%2F10.1016%252FS0016-5085%252877%252980135-2&rfr_id=info%3Asid%2Fen.wikipedia.org%3AHepatic+encephalopathy" class="Z3988"></span></span> </li> <li id="cite_note-Boyer-30"><span class="mw-cite-backlink"><b><a href="#cite_ref-Boyer_30-0">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1238218222"><cite id="CITEREFBoyerGarcia-TsaoGroszmann2012" class="citation journal cs1">Boyer JL, Garcia-Tsao G, Groszmann RJ (February 2012). <a rel="nofollow" class="external text" href="https://doi.org/10.1002%2Fhep.25550">"In Memoriam: Harold O. Conn, M.D."</a> <i>Hepatology</i>. <b>55</b> (2): 658–9. <a href="/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://doi.org/10.1002%2Fhep.25550">10.1002/hep.25550</a></span>. <a href="/wiki/S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a rel="nofollow" class="external text" href="https://api.semanticscholar.org/CorpusID:85090164">85090164</a>.</cite><span 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dd:last-child::after,.mw-parser-output .hlist li dt:last-child::after,.mw-parser-output .hlist li li:last-child::after{content:")";font-weight:normal}.mw-parser-output .hlist ol{counter-reset:listitem}.mw-parser-output .hlist ol>li{counter-increment:listitem}.mw-parser-output .hlist ol>li::before{content:" "counter(listitem)"\a0 "}.mw-parser-output .hlist dd ol>li:first-child::before,.mw-parser-output .hlist dt ol>li:first-child::before,.mw-parser-output .hlist li ol>li:first-child::before{content:" ("counter(listitem)"\a0 "}</style><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"></div><div role="navigation" class="navbox" aria-label="Navbox" style="width:100%; margin:0.5em 0 0.5em 0;;padding:3px"><table class="nowraplinks navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="row" class="navbox-group" style="width:1%;background: #EAECF0;color:black;">Classification</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"><div style="position:relative; float:right; font-size:0.8em;"><a href="https://www.wikidata.org/wiki/Q642548" class="extiw" title="d:Q642548">D</a></div><div class="hlist" style="text-align:left;"><ul><li><b><a href="/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problems" class="mw-redirect" title="International Statistical Classification of Diseases and Related Health Problems">ICD</a>-<a href="/wiki/ICD-10" title="ICD-10">10</a></b>: <a rel="nofollow" class="external text" href="https://icd.who.int/browse10/2019/en#/K72">K72</a></li><li><b><a href="/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problems" class="mw-redirect" title="International Statistical Classification of Diseases and Related Health Problems">ICD</a>-<a href="/wiki/List_of_ICD-9_codes" title="List of ICD-9 codes">9-CM</a></b>: <a rel="nofollow" class="external text" href="http://www.icd9data.com/getICD9Code.ashx?icd9=572.2">572.2</a></li><li><b><a href="/wiki/Medical_Subject_Headings" title="Medical Subject Headings">MeSH</a></b>: <a rel="nofollow" class="external text" href="https://meshb.nlm.nih.gov/record/ui?ui=D006501">D006501</a></li></ul></div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%;background: #EAECF0;color:black;">External resources</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"><div class="hlist" style="text-align:left;"><ul><li><b><a href="/wiki/MedlinePlus" title="MedlinePlus">MedlinePlus</a></b>: <a rel="nofollow" class="external text" href="https://www.nlm.nih.gov/medlineplus/ency/article/000302.htm">000302</a></li><li><b><a href="/wiki/EMedicine" title="EMedicine">eMedicine</a></b>: <a rel="nofollow" class="external text" href="https://emedicine.medscape.com/med/3185-overview">med/3185</a> <a rel="nofollow" class="external text" href="https://emedicine.medscape.com/article/182208-overview">article/182208</a></li></ul></div></div></td></tr></tbody></table></div> <div class="navbox-styles"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1236075235"></div><div role="navigation" class="navbox" aria-labelledby="Diseases_of_the_nervous_system,_primarily_CNS" style="padding:3px"><table class="nowraplinks mw-collapsible autocollapse navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="col" class="navbox-title" colspan="2"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><style data-mw-deduplicate="TemplateStyles:r1239400231">.mw-parser-output .navbar{display:inline;font-size:88%;font-weight:normal}.mw-parser-output .navbar-collapse{float:left;text-align:left}.mw-parser-output .navbar-boxtext{word-spacing:0}.mw-parser-output .navbar ul{display:inline-block;white-space:nowrap;line-height:inherit}.mw-parser-output .navbar-brackets::before{margin-right:-0.125em;content:"[ "}.mw-parser-output .navbar-brackets::after{margin-left:-0.125em;content:" ]"}.mw-parser-output .navbar li{word-spacing:-0.125em}.mw-parser-output .navbar a>span,.mw-parser-output .navbar a>abbr{text-decoration:inherit}.mw-parser-output .navbar-mini abbr{font-variant:small-caps;border-bottom:none;text-decoration:none;cursor:inherit}.mw-parser-output .navbar-ct-full{font-size:114%;margin:0 7em}.mw-parser-output .navbar-ct-mini{font-size:114%;margin:0 4em}html.skin-theme-clientpref-night .mw-parser-output .navbar li a abbr{color:var(--color-base)!important}@media(prefers-color-scheme:dark){html.skin-theme-clientpref-os .mw-parser-output .navbar li a abbr{color:var(--color-base)!important}}@media print{.mw-parser-output .navbar{display:none!important}}</style><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a href="/wiki/Template:Central_nervous_system_disease" title="Template:Central nervous system disease"><abbr title="View this template">v</abbr></a></li><li class="nv-talk"><a href="/wiki/Template_talk:Central_nervous_system_disease" title="Template talk:Central nervous system disease"><abbr title="Discuss this template">t</abbr></a></li><li class="nv-edit"><a href="/wiki/Special:EditPage/Template:Central_nervous_system_disease" title="Special:EditPage/Template:Central nervous system disease"><abbr title="Edit this template">e</abbr></a></li></ul></div><div id="Diseases_of_the_nervous_system,_primarily_CNS" style="font-size:114%;margin:0 4em">Diseases of the <a href="/wiki/Nervous_system" title="Nervous system">nervous system</a>, primarily <a href="/wiki/Central_nervous_system_disease" title="Central nervous system disease">CNS</a></div></th></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Inflammation" title="Inflammation">Inflammation</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th id="Brain" scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Human_brain" title="Human brain">Brain</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Encephalitis" title="Encephalitis">Encephalitis</a> <ul><li><a href="/wiki/Viral_encephalitis" title="Viral encephalitis">Viral encephalitis</a></li> <li><a href="/wiki/Herpesviral_encephalitis" class="mw-redirect" title="Herpesviral encephalitis">Herpesviral encephalitis</a></li> <li><a href="/wiki/Limbic_encephalitis" title="Limbic encephalitis">Limbic encephalitis</a></li> <li><a href="/wiki/Encephalitis_lethargica" title="Encephalitis lethargica">Encephalitis lethargica</a></li></ul></li> <li><a href="/wiki/Cavernous_sinus_thrombosis" title="Cavernous sinus thrombosis">Cavernous sinus thrombosis</a></li> <li><a href="/wiki/Brain_abscess" title="Brain abscess">Brain abscess</a> <ul><li><a href="/wiki/Amoebic_brain_abscess" title="Amoebic brain abscess">Amoebic</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Brain and <a href="/wiki/Spinal_cord" title="Spinal cord">spinal cord</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Encephalomyelitis" title="Encephalomyelitis">Encephalomyelitis</a> <ul><li><a href="/wiki/Acute_disseminated_encephalomyelitis" title="Acute disseminated encephalomyelitis">Acute disseminated</a></li></ul></li> <li><a href="/wiki/Meningitis" title="Meningitis">Meningitis</a></li> <li><a href="/wiki/Meningoencephalitis" title="Meningoencephalitis">Meningoencephalitis</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Human_brain" title="Human brain">Brain</a>/<br /><a href="/wiki/Encephalopathy" title="Encephalopathy">encephalopathy</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Neurodegenerative_disease" title="Neurodegenerative disease">Degenerative</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Extrapyramidal_system" title="Extrapyramidal system">Extrapyramidal</a> and<br /><a href="/wiki/Movement_disorders" class="mw-redirect" title="Movement disorders">movement disorders</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Basal_ganglia_disease" title="Basal ganglia disease">Basal ganglia disease</a> <ul><li><a href="/wiki/Parkinsonism" title="Parkinsonism">Parkinsonism</a> <ul><li><a href="/wiki/Parkinson%27s_disease" title="Parkinson's disease">PD</a></li> <li><a href="/wiki/Postencephalitic_parkinsonism" class="mw-redirect" title="Postencephalitic parkinsonism">Postencephalitic</a></li> <li><a href="/wiki/Neuroleptic_malignant_syndrome" title="Neuroleptic malignant syndrome">NMS</a></li></ul></li> <li><a href="/wiki/Neurodegeneration_with_brain_iron_accumulation" title="Neurodegeneration with brain iron accumulation">NBIA</a> <ul><li><a href="/wiki/Pantothenate_kinase-associated_neurodegeneration" title="Pantothenate kinase-associated neurodegeneration">PKAN</a></li></ul></li> <li><a href="/wiki/Tauopathy" title="Tauopathy">Tauopathy</a> <ul><li><a href="/wiki/Progressive_supranuclear_palsy" title="Progressive supranuclear palsy">PSP</a></li></ul></li> <li><a href="/wiki/Multiple_system_atrophy" title="Multiple system atrophy">Striatonigral degeneration</a></li> <li><a href="/wiki/Hemiballismus" title="Hemiballismus">Hemiballismus</a></li> <li><a href="/wiki/Huntington%27s_disease" title="Huntington's disease">HD</a></li> <li><a href="/wiki/Olivopontocerebellar_atrophy" class="mw-redirect" title="Olivopontocerebellar atrophy">OA</a></li></ul></li></ul> <ul><li><a href="/wiki/Dyskinesia" title="Dyskinesia">Dyskinesia</a> <ul><li><a href="/wiki/Dystonia" title="Dystonia">Dystonia</a> <ul><li><a href="/wiki/Status_dystonicus" title="Status dystonicus">Status dystonicus</a></li> <li><a href="/wiki/Spasmodic_torticollis" title="Spasmodic torticollis">Spasmodic torticollis</a></li> <li><a href="/wiki/Meige%27s_syndrome" title="Meige's syndrome">Meige's</a></li> <li><a href="/wiki/Blepharospasm" title="Blepharospasm">Blepharospasm</a></li></ul></li> <li><a href="/wiki/Athetosis" title="Athetosis">Athetosis</a></li> <li><a href="/wiki/Chorea" title="Chorea">Chorea</a> <ul><li><a href="/wiki/Choreoathetosis" title="Choreoathetosis">Choreoathetosis</a></li></ul></li> <li><a href="/wiki/Myoclonus" title="Myoclonus">Myoclonus</a> <ul><li><a href="/wiki/Myoclonic_epilepsy" title="Myoclonic epilepsy">Myoclonic epilepsy</a></li></ul></li> <li><a href="/wiki/Akathisia" title="Akathisia">Akathisia</a></li></ul></li></ul> <ul><li><a href="/wiki/Tremor" title="Tremor">Tremor</a> <ul><li><a href="/wiki/Essential_tremor" title="Essential tremor">Essential tremor</a></li> <li><a href="/wiki/Intention_tremor" title="Intention tremor">Intention tremor</a></li></ul></li> <li><a href="/wiki/Restless_legs_syndrome" title="Restless legs syndrome">Restless legs</a></li> <li><a href="/wiki/Stiff-person_syndrome" title="Stiff-person syndrome">Stiff-person</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Dementia" title="Dementia">Dementia</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Tauopathy" title="Tauopathy">Tauopathy</a> <ul><li><a href="/wiki/Alzheimer%27s_disease" title="Alzheimer's disease">Alzheimer's</a> <ul><li><a href="/wiki/Early-onset_Alzheimer%27s_disease" title="Early-onset Alzheimer's disease">Early-onset</a></li></ul></li> <li><a href="/wiki/Primary_progressive_aphasia" title="Primary progressive aphasia">Primary progressive aphasia</a></li></ul></li> <li><a href="/wiki/Frontotemporal_dementia" title="Frontotemporal dementia">Frontotemporal dementia</a>/<a href="/wiki/Frontotemporal_lobar_degeneration" title="Frontotemporal lobar degeneration">Frontotemporal lobar degeneration</a> <ul><li><a href="/wiki/Pick%27s_disease" class="mw-redirect" title="Pick's disease">Pick's</a></li></ul></li> <li><a href="/wiki/Lewy_bodies_dementia" class="mw-redirect" title="Lewy bodies dementia">Lewy bodies dementia</a></li> <li><a href="/wiki/Posterior_cortical_atrophy" title="Posterior cortical atrophy">Posterior cortical atrophy</a></li></ul> <p><a href="/wiki/Creutzfeldt%E2%80%93Jakob_disease" title="Creutzfeldt–Jakob disease">Creutzfeldt–Jakob disease</a> </p> <ul><li><a href="/wiki/Vascular_dementia" title="Vascular dementia">Vascular dementia</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Mitochondrial_disease" title="Mitochondrial disease">Mitochondrial disease</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Leigh_syndrome" title="Leigh syndrome">Leigh syndrome</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Demyelinating_disease" title="Demyelinating disease">Demyelinating</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/CNS_demyelinating_autoimmune_diseases" title="CNS demyelinating autoimmune diseases">Autoimmune</a></li> <li><a href="/wiki/Inflammatory_demyelinating_diseases_of_the_central_nervous_system" title="Inflammatory demyelinating diseases of the central nervous system">Inflammatory</a></li> <li><a href="/wiki/Multiple_sclerosis" title="Multiple sclerosis">Multiple sclerosis</a></li> <li>For more detailed coverage, see <a href="/wiki/Template:Demyelinating_diseases_of_CNS" title="Template:Demyelinating diseases of CNS">Template:Demyelinating diseases of CNS</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Episodic/<br /><a href="/wiki/Paroxysmal_attack" title="Paroxysmal attack">paroxysmal</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Epileptic_seizure" class="mw-redirect" title="Epileptic seizure">Seizures</a> and <a href="/wiki/Epilepsy" title="Epilepsy">epilepsy</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Focal_seizure" title="Focal seizure">Focal</a></li> <li><a href="/wiki/Generalized_epilepsy" title="Generalized epilepsy">Generalised</a></li> <li><a href="/wiki/Status_epilepticus" title="Status epilepticus">Status epilepticus</a></li> <li>For more detailed coverage, see <a href="/wiki/Template:Epilepsy" class="mw-redirect" title="Template:Epilepsy">Template:Epilepsy</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Headache" title="Headache">Headache</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Migraine" title="Migraine">Migraine</a></li> <li><a href="/wiki/Cluster_headache" title="Cluster headache">Cluster</a></li> <li><a href="/wiki/Tension_headache" title="Tension headache">Tension</a></li> <li>For more detailed coverage, see <a href="/wiki/Template:Headache" title="Template:Headache">Template:Headache</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Cerebrovascular_disease" title="Cerebrovascular disease">Cerebrovascular</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Transient_ischemic_attack" title="Transient ischemic attack">TIA</a></li> <li><a href="/wiki/Stroke" title="Stroke">Stroke</a></li> <li>For more detailed coverage, see <a href="/wiki/Template:Cerebrovascular_diseases" title="Template:Cerebrovascular diseases">Template:Cerebrovascular diseases</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Other</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Sleep_disorders" class="mw-redirect" title="Sleep disorders">Sleep disorders</a> <ul><li>For more detailed coverage, see <a href="/wiki/Template:Sleep" title="Template:Sleep">Template:Sleep</a></li></ul></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Cerebrospinal_fluid" title="Cerebrospinal fluid">CSF</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Intracranial_pressure" title="Intracranial pressure">Intracranial hypertension</a> <ul><li><a href="/wiki/Hydrocephalus" title="Hydrocephalus">Hydrocephalus</a></li> <li><a href="/wiki/Normal_pressure_hydrocephalus" title="Normal pressure hydrocephalus">Normal pressure hydrocephalus</a></li> <li><a href="/wiki/Choroid_plexus_papilloma" title="Choroid plexus papilloma">Choroid plexus papilloma</a></li> <li><a href="/wiki/Idiopathic_intracranial_hypertension" title="Idiopathic intracranial hypertension">Idiopathic intracranial hypertension</a></li></ul></li> <li><a href="/wiki/Cerebral_edema" title="Cerebral edema">Cerebral edema</a></li> <li><a href="/wiki/Spontaneous_cerebrospinal_fluid_leak" class="mw-redirect" title="Spontaneous cerebrospinal fluid leak">Intracranial hypotension</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Other</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Brain_herniation" title="Brain herniation">Brain herniation</a></li> <li><a href="/wiki/Reye_syndrome" title="Reye syndrome">Reye syndrome</a></li> <li><a class="mw-selflink selflink">Hepatic encephalopathy</a></li> <li><a href="/wiki/Toxic_encephalopathy" title="Toxic encephalopathy">Toxic encephalopathy</a></li> <li><a href="/wiki/Hashimoto%27s_encephalopathy" title="Hashimoto's encephalopathy">Hashimoto's encephalopathy</a></li> <li><a href="/wiki/Fetal_alcohol_spectrum_disorder" title="Fetal alcohol spectrum disorder">Static encephalopathy</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Both/either</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th id="Degenerative" scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Neurodegenerative_disease" title="Neurodegenerative disease">Degenerative</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Spinocerebellar_ataxia" title="Spinocerebellar ataxia">SA</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Friedreich%27s_ataxia" title="Friedreich's ataxia">Friedreich's ataxia</a></li> <li><a href="/wiki/Ataxia%E2%80%93telangiectasia" title="Ataxia–telangiectasia">Ataxia–telangiectasia</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Motor_neuron_diseases" title="Motor neuron diseases">MND</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><i><a href="/wiki/Upper_motor_neuron" title="Upper motor neuron">UMN</a> only:</i> <ul><li><a href="/wiki/Primary_lateral_sclerosis" title="Primary lateral sclerosis">Primary lateral sclerosis</a></li> <li><a href="/wiki/Pseudobulbar_palsy" title="Pseudobulbar palsy">Pseudobulbar palsy</a></li> <li><a href="/wiki/Hereditary_spastic_paraplegia" title="Hereditary spastic paraplegia">Hereditary spastic paraplegia</a></li></ul></li></ul> <ul><li><i><a href="/wiki/Lower_motor_neuron" title="Lower motor neuron">LMN</a> only:</i> <ul><li><a href="/wiki/Distal_hereditary_motor_neuronopathies" title="Distal hereditary motor neuronopathies">Distal hereditary motor neuronopathies</a></li> <li><a href="/wiki/Spinal_muscular_atrophies" title="Spinal muscular atrophies">Spinal muscular atrophies</a> <ul><li><a href="/wiki/Spinal_muscular_atrophy" title="Spinal muscular atrophy">SMA</a></li> <li><a href="/wiki/Spinal_and_bulbar_muscular_atrophy" title="Spinal and bulbar muscular atrophy">SMAX1</a></li> <li><a href="/wiki/X-linked_spinal_muscular_atrophy_type_2" title="X-linked spinal muscular atrophy type 2">SMAX2</a></li> <li><a href="/wiki/Distal_spinal_muscular_atrophy_type_1" title="Distal spinal muscular atrophy type 1">DSMA1</a></li> <li><a href="/wiki/Congenital_distal_spinal_muscular_atrophy" title="Congenital distal spinal muscular atrophy">Congenital DSMA</a></li> <li>Spinal muscular atrophy with lower extremity predominance (SMALED) <ul><li><a href="/wiki/Spinal_muscular_atrophy_with_lower_extremity_predominance_1" title="Spinal muscular atrophy with lower extremity predominance 1">SMALED1</a></li> <li><a href="/wiki/Spinal_muscular_atrophy_with_lower_extremity_predominance_2A" title="Spinal muscular atrophy with lower extremity predominance 2A">SMALED2A</a></li> <li><a href="/wiki/Spinal_muscular_atrophy_with_lower_extremity_predominance_2B" title="Spinal muscular atrophy with lower extremity predominance 2B">SMALED2B</a></li></ul></li> <li><a href="/wiki/Pontocerebellar_hypoplasia" title="Pontocerebellar hypoplasia">SMA-PCH</a></li> <li><a href="/wiki/Spinal_muscular_atrophy_with_progressive_myoclonic_epilepsy" title="Spinal muscular atrophy with progressive myoclonic epilepsy">SMA-PME</a></li></ul></li> <li><a href="/wiki/Progressive_muscular_atrophy" title="Progressive muscular atrophy">Progressive muscular atrophy</a></li> <li><a href="/wiki/Progressive_bulbar_palsy" title="Progressive bulbar palsy">Progressive bulbar palsy</a> <ul><li><a href="/wiki/Fazio%E2%80%93Londe_disease" title="Fazio–Londe disease">Fazio–Londe</a></li> <li><a href="/wiki/Infantile_progressive_bulbar_palsy" title="Infantile progressive bulbar palsy">Infantile progressive bulbar palsy</a></li></ul></li></ul></li></ul> <ul><li><i>both:</i> <ul><li><a href="/wiki/Amyotrophic_lateral_sclerosis" class="mw-redirect" title="Amyotrophic lateral sclerosis">Amyotrophic lateral sclerosis</a></li></ul></li></ul> </div></td></tr></tbody></table><div></div></td></tr></tbody></table><div></div></td></tr></tbody></table></div> <div class="navbox-styles"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1236075235"></div><div role="navigation" class="navbox" aria-labelledby="Diseases_of_the_human_digestive_system" style="padding:3px"><table class="nowraplinks mw-collapsible mw-collapsed navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="col" class="navbox-title" colspan="2"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1239400231"><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a href="/wiki/Template:Digestive_system_diseases" title="Template:Digestive system diseases"><abbr title="View this template">v</abbr></a></li><li class="nv-talk"><a href="/wiki/Template_talk:Digestive_system_diseases" title="Template talk:Digestive system diseases"><abbr title="Discuss this template">t</abbr></a></li><li class="nv-edit"><a href="/wiki/Special:EditPage/Template:Digestive_system_diseases" title="Special:EditPage/Template:Digestive system diseases"><abbr title="Edit this template">e</abbr></a></li></ul></div><div id="Diseases_of_the_human_digestive_system" style="font-size:114%;margin:0 4em">Diseases of the <a href="/wiki/Human_digestive_system" title="Human digestive system">human digestive system</a></div></th></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Gastrointestinal_tract#Upper_gastrointestinal_tract" title="Gastrointestinal tract">Upper GI tract</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Esophageal_disease" title="Esophageal disease">Esophagus</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Esophagitis" title="Esophagitis">Esophagitis</a> <ul><li><a href="/wiki/Esophageal_candidiasis" title="Esophageal candidiasis">Candidal</a></li> <li><a href="/wiki/Eosinophilic_esophagitis" title="Eosinophilic esophagitis">Eosinophilic</a></li> <li><a href="/wiki/Herpetiform_esophagitis" class="mw-redirect" title="Herpetiform esophagitis">Herpetiform</a></li></ul></li> <li><i>Rupture</i> <ul><li><a href="/wiki/Boerhaave_syndrome" class="mw-redirect" title="Boerhaave syndrome">Boerhaave syndrome</a></li> <li><a href="/wiki/Mallory%E2%80%93Weiss_syndrome" title="Mallory–Weiss syndrome">Mallory–Weiss syndrome</a></li></ul></li> <li><a href="/wiki/Zenker%27s_diverticulum" title="Zenker's diverticulum">Zenker's diverticulum</a></li> <li><a href="/wiki/Barrett%27s_esophagus" title="Barrett's esophagus">Barrett's esophagus</a></li> <li><a href="/wiki/Esophageal_motility_disorder" title="Esophageal motility disorder">Esophageal motility disorder</a> <ul><li><a href="/wiki/Nutcracker_esophagus" title="Nutcracker esophagus">Nutcracker esophagus</a></li> <li><a href="/wiki/Achalasia" class="mw-redirect" title="Achalasia">Achalasia</a></li> <li><a href="/wiki/Esophagogastric_junction_outflow_obstruction" title="Esophagogastric junction outflow obstruction">Esophagogastric junction outflow obstruction</a></li> <li><a href="/wiki/Diffuse_esophageal_spasm" title="Diffuse esophageal spasm">Diffuse esophageal spasm</a></li> <li><a href="/wiki/Gastroesophageal_reflux_disease" title="Gastroesophageal reflux disease">Gastroesophageal reflux disease</a> (GERD)</li></ul></li> <li><a href="/wiki/Laryngopharyngeal_reflux" title="Laryngopharyngeal reflux">Laryngopharyngeal reflux</a> (LPR)</li> <li><a href="/wiki/Esophageal_stricture" title="Esophageal stricture">Esophageal stricture</a></li> <li><a href="/wiki/Esophageal_inlet_patch" title="Esophageal inlet patch">Inlet patch</a></li> <li><a href="/wiki/Megaesophagus" title="Megaesophagus">Megaesophagus</a></li> <li><a href="/wiki/Esophageal_intramural_pseudodiverticulosis" title="Esophageal intramural pseudodiverticulosis">Esophageal intramural pseudodiverticulosis</a></li> <li><a href="/wiki/Acute_esophageal_necrosis" title="Acute esophageal necrosis">Acute esophageal necrosis</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Stomach_disease" title="Stomach disease">Stomach</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Gastritis" title="Gastritis">Gastritis</a> <ul><li><a href="/wiki/Atrophic_gastritis" title="Atrophic gastritis">Atrophic</a></li> <li><a href="/wiki/M%C3%A9n%C3%A9trier%27s_disease" title="Ménétrier's disease">Ménétrier's disease</a></li> <li><a href="/wiki/Gastroenteritis" title="Gastroenteritis">Gastroenteritis</a></li></ul></li> <li><a href="/wiki/Peptic_ulcer" class="mw-redirect" title="Peptic ulcer">Peptic (gastric) ulcer</a> <ul><li><a href="/wiki/Cushing_ulcer" title="Cushing ulcer">Cushing ulcer</a></li> <li><a href="/wiki/Dieulafoy%27s_lesion" title="Dieulafoy's lesion">Dieulafoy's lesion</a></li></ul></li> <li><a href="/wiki/Dyspepsia" class="mw-redirect" title="Dyspepsia">Dyspepsia</a> <ul><li><a href="/wiki/Functional_dyspepsia" title="Functional dyspepsia">Functional dyspepsia</a></li></ul></li> <li><a href="/wiki/Pyloric_stenosis" title="Pyloric stenosis">Pyloric stenosis</a></li> <li><a href="/wiki/Achlorhydria" title="Achlorhydria">Achlorhydria</a></li> <li><a href="/wiki/Gastroparesis" title="Gastroparesis">Gastroparesis</a></li> <li><a href="/wiki/Gastroptosis" title="Gastroptosis">Gastroptosis</a></li> <li><a href="/wiki/Portal_hypertensive_gastropathy" title="Portal hypertensive gastropathy">Portal hypertensive gastropathy</a></li> <li><a href="/wiki/Gastric_antral_vascular_ectasia" title="Gastric antral vascular ectasia">Gastric antral vascular ectasia</a></li> <li><a href="/wiki/Gastric_dumping_syndrome" class="mw-redirect" title="Gastric dumping syndrome">Gastric dumping syndrome</a></li> <li><a href="/wiki/Gastric_volvulus" title="Gastric volvulus">Gastric volvulus</a></li> <li><a href="/wiki/Buried_bumper_syndrome" title="Buried bumper syndrome">Buried bumper syndrome</a></li> <li><a href="/wiki/Gastrinoma" title="Gastrinoma">Gastrinoma</a> <ul><li><a href="/wiki/Zollinger%E2%80%93Ellison_syndrome" title="Zollinger–Ellison syndrome">Zollinger–Ellison syndrome</a></li></ul></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Gastrointestinal_tract#Lower_gastrointestinal_tract" title="Gastrointestinal tract">Lower GI tract</a> <br /> <a href="/wiki/Enteropathy" title="Enteropathy">Enteropathy</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Small_intestine" title="Small intestine">Small intestine</a> <br /> (<a href="/wiki/Duodenum" title="Duodenum">Duodenum</a>/<a href="/wiki/Jejunum" title="Jejunum">Jejunum</a>/<a href="/wiki/Ileum" title="Ileum">Ileum</a>)</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Enteritis" title="Enteritis">Enteritis</a> <ul><li><a href="/wiki/Duodenitis" title="Duodenitis">Duodenitis</a></li> <li><a href="/wiki/Jejunitis" title="Jejunitis">Jejunitis</a></li> <li><a href="/wiki/Ileitis" title="Ileitis">Ileitis</a></li></ul></li> <li><a href="/wiki/Peptic_ulcer" class="mw-redirect" title="Peptic ulcer">Peptic (duodenal) ulcer</a> <ul><li><a href="/wiki/Curling%27s_ulcer" title="Curling's ulcer">Curling's ulcer</a></li></ul></li> <li><a href="/wiki/Malabsorption" title="Malabsorption">Malabsorption</a>: <a href="/wiki/Coeliac_disease" title="Coeliac disease">Coeliac</a></li> <li><a href="/wiki/Tropical_sprue" title="Tropical sprue">Tropical sprue</a></li> <li><a href="/wiki/Blind_loop_syndrome" title="Blind loop syndrome">Blind loop syndrome</a></li> <li><a href="/wiki/Small_intestinal_bacterial_overgrowth" title="Small intestinal bacterial overgrowth">Small intestinal bacterial overgrowth</a></li> <li><a href="/wiki/Whipple%27s_disease" title="Whipple's disease">Whipple's</a></li> <li><a href="/wiki/Short_bowel_syndrome" title="Short bowel syndrome">Short bowel syndrome</a></li> <li><a href="/wiki/Steatorrhea" title="Steatorrhea">Steatorrhea</a></li> <li><a href="/wiki/Milroy_disease" class="mw-redirect" title="Milroy disease">Milroy disease</a></li> <li><a href="/wiki/Bile_acid_malabsorption" title="Bile acid malabsorption">Bile acid malabsorption</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Large_intestine" title="Large intestine">Large intestine</a> <br /> (<a href="/wiki/Vermiform_appendix" class="mw-redirect" title="Vermiform appendix">Appendix</a>/<a href="/wiki/Colon_(anatomy)" class="mw-redirect" title="Colon (anatomy)">Colon</a>)</th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Appendicitis" title="Appendicitis">Appendicitis</a></li> <li><a href="/wiki/Colitis" title="Colitis">Colitis</a> <ul><li><a href="/wiki/Pseudomembranous_colitis" class="mw-redirect" title="Pseudomembranous colitis">Pseudomembranous</a></li> <li><a href="/wiki/Ulcerative_colitis" title="Ulcerative colitis">Ulcerative</a></li> <li><a href="/wiki/Ischemic_colitis" title="Ischemic colitis">Ischemic</a></li> <li><a href="/wiki/Microscopic_colitis" title="Microscopic colitis">Microscopic</a></li> <li><a href="/wiki/Collagenous_colitis" title="Collagenous colitis">Collagenous</a></li> <li><a href="/wiki/Lymphocytic_colitis" title="Lymphocytic colitis">Lymphocytic</a></li></ul></li> <li><a href="/wiki/Dysentery" title="Dysentery">Dysentery</a></li> <li><a href="/wiki/Functional_colonic_disease" class="mw-redirect" title="Functional colonic disease">Functional colonic disease</a> <ul><li><a href="/wiki/Irritable_bowel_syndrome" title="Irritable bowel syndrome">IBS</a></li> <li><a href="/wiki/Intestinal_pseudoobstruction" class="mw-redirect" title="Intestinal pseudoobstruction">Intestinal pseudoobstruction</a> / <a href="/wiki/Ogilvie_syndrome" title="Ogilvie syndrome">Ogilvie syndrome</a></li></ul></li> <li><a href="/wiki/Megacolon" title="Megacolon">Megacolon</a> / <a href="/wiki/Toxic_megacolon" title="Toxic megacolon">Toxic megacolon</a></li> <li><a href="/wiki/Diverticulitis" title="Diverticulitis">Diverticulitis</a>/<a href="/wiki/Diverticulosis" title="Diverticulosis">Diverticulosis</a>/<a href="/wiki/Segmental_colitis_associated_with_diverticulosis" title="Segmental colitis associated with diverticulosis">SCAD</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Large and/or small</th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Enterocolitis" title="Enterocolitis">Enterocolitis</a> <ul><li><a href="/wiki/Necrotizing_enterocolitis" title="Necrotizing enterocolitis">Necrotizing</a></li></ul></li> <li><a href="/wiki/Gastroenterocolitis" title="Gastroenterocolitis">Gastroenterocolitis</a></li> <li><a href="/wiki/Inflammatory_bowel_disease" title="Inflammatory bowel disease">IBD</a> <ul><li><a href="/wiki/Crohn%27s_disease" title="Crohn's disease">Crohn's disease</a></li></ul></li> <li><i><a href="/wiki/Vascular_disease" title="Vascular disease">Vascular</a></i>: <a href="/wiki/Abdominal_angina" title="Abdominal angina">Abdominal angina</a></li> <li><a href="/wiki/Mesenteric_ischemia" class="mw-redirect" title="Mesenteric ischemia">Mesenteric ischemia</a></li> <li><a href="/wiki/Angiodysplasia" title="Angiodysplasia">Angiodysplasia</a></li> <li><a href="/wiki/Bowel_obstruction" title="Bowel obstruction">Bowel obstruction</a>: <a href="/wiki/Ileus" title="Ileus">Ileus</a></li> <li><a href="/wiki/Intussusception_(medical_disorder)" title="Intussusception (medical disorder)">Intussusception</a></li> <li><a href="/wiki/Volvulus" title="Volvulus">Volvulus</a></li> <li><a href="/wiki/Fecal_impaction" title="Fecal impaction">Fecal impaction</a></li> <li><a href="/wiki/Constipation" title="Constipation">Constipation</a> <ul><li><a href="/wiki/Functional_constipation" title="Functional constipation">Functional</a></li></ul></li> <li><a href="/wiki/Diarrhea" title="Diarrhea">Diarrhea</a> <ul><li><a href="/wiki/Infectious_diarrhea" class="mw-redirect" title="Infectious diarrhea">Infectious</a></li></ul></li> <li><a href="/wiki/Adhesion_(medicine)" title="Adhesion (medicine)">Intestinal adhesions</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Rectum" title="Rectum">Rectum</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Proctitis" title="Proctitis">Proctitis</a> <ul><li><a href="/wiki/Radiation_proctitis" title="Radiation proctitis">Radiation proctitis</a></li></ul></li> <li><a href="/wiki/Proctalgia_fugax" title="Proctalgia fugax">Proctalgia fugax</a></li> <li><a href="/wiki/Rectal_prolapse" title="Rectal prolapse">Rectal prolapse</a></li> <li><a href="/wiki/Anismus" title="Anismus">Anismus</a></li> <li><a href="/wiki/Solitary_rectal_ulcer_syndrome" title="Solitary rectal ulcer syndrome">Solitary rectal ulcer syndrome</a></li> <li><a href="/wiki/Rectal_stricture" title="Rectal stricture">Rectal stricture</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Anal_canal" title="Anal canal">Anal canal</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Anal_fissure" title="Anal fissure">Anal fissure</a>/<a href="/wiki/Anal_fistula" title="Anal fistula">Anal fistula</a></li> <li><a href="/wiki/Anal_abscess" class="mw-redirect" title="Anal abscess">Anal abscess</a></li> <li><a href="/wiki/Hemorrhoid" title="Hemorrhoid">Hemorrhoid</a></li> <li><a href="/wiki/Anal_dysplasia" title="Anal dysplasia">Anal dysplasia</a></li> <li><a href="/wiki/Pruritus_ani" title="Pruritus ani">Pruritus ani</a></li> <li><a href="/wiki/Anal_stricture" title="Anal stricture">Anal stricture</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Gastrointestinal_bleeding" title="Gastrointestinal bleeding">GI bleeding</a></th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Blood_in_stool" title="Blood in stool">Blood in stool</a></li> <li><a href="/wiki/Upper_gastrointestinal_bleeding" title="Upper gastrointestinal bleeding">Upper</a> <ul><li><a href="/wiki/Hematemesis" title="Hematemesis">Hematemesis</a></li> <li><a href="/wiki/Melena" title="Melena">Melena</a></li></ul></li> <li><a href="/wiki/Lower_gastrointestinal_bleeding" title="Lower gastrointestinal bleeding">Lower</a> <ul><li><a href="/wiki/Hematochezia" title="Hematochezia">Hematochezia</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Accessory_digestive_gland" class="mw-redirect" title="Accessory digestive gland">Accessory</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Liver_disease" title="Liver disease">Liver</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Hepatitis" title="Hepatitis">Hepatitis</a> <ul><li><a href="/wiki/Viral_hepatitis" title="Viral hepatitis">Viral hepatitis</a></li> <li><a href="/wiki/Autoimmune_hepatitis" title="Autoimmune hepatitis">Autoimmune hepatitis</a></li> <li><a href="/wiki/Alcoholic_hepatitis" title="Alcoholic hepatitis">Alcoholic hepatitis</a></li></ul></li> <li><a href="/wiki/Cirrhosis" title="Cirrhosis">Cirrhosis</a> <ul><li><a href="/wiki/Primary_biliary_cirrhosis" class="mw-redirect" title="Primary biliary cirrhosis">PBC</a></li></ul></li> <li><a href="/wiki/Fatty_liver" class="mw-redirect" title="Fatty liver">Fatty liver</a> <ul><li><a href="/wiki/Metabolic_dysfunction%E2%80%93associated_steatotic_liver_disease" title="Metabolic dysfunction–associated steatotic liver disease">MASLD</a></li></ul></li> <li><i><a href="/wiki/Vascular_disease" title="Vascular disease">Vascular</a></i> <ul><li><a href="/wiki/Budd%E2%80%93Chiari_syndrome" title="Budd–Chiari syndrome">Budd–Chiari syndrome</a></li> <li><a href="/wiki/Hepatic_veno-occlusive_disease" title="Hepatic veno-occlusive disease">Hepatic veno-occlusive disease</a></li> <li><a href="/wiki/Portal_hypertension" title="Portal hypertension">Portal hypertension</a></li> <li><a href="/wiki/Nutmeg_liver" class="mw-redirect" title="Nutmeg liver">Nutmeg liver</a></li></ul></li> <li><a href="/wiki/Alcoholic_liver_disease" title="Alcoholic liver disease">Alcoholic liver disease</a></li> <li><a href="/wiki/Liver_failure" title="Liver failure">Liver failure</a> <ul><li><a class="mw-selflink selflink">Hepatic encephalopathy</a></li> <li><a href="/wiki/Acute_liver_failure" title="Acute liver failure">Acute liver failure</a></li></ul></li> <li><a href="/wiki/Liver_abscess" title="Liver abscess">Liver abscess</a> <ul><li><a href="/wiki/Pyogenic_liver_abscess" title="Pyogenic liver abscess">Pyogenic</a></li> <li><a href="/wiki/Amoebic_liver_abscess" title="Amoebic liver abscess">Amoebic</a></li></ul></li> <li><a href="/wiki/Hepatorenal_syndrome" title="Hepatorenal syndrome">Hepatorenal syndrome</a></li> <li><a href="/wiki/Peliosis_hepatis" title="Peliosis hepatis">Peliosis hepatis</a></li> <li><a href="/wiki/Metabolic_disorder" title="Metabolic disorder">Metabolic disorders</a> <ul><li><a href="/wiki/Wilson%27s_disease" title="Wilson's disease">Wilson's disease</a></li> <li><a href="/wiki/Hemochromatosis" class="mw-redirect" title="Hemochromatosis">Hemochromatosis</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Gallbladder_disease" title="Gallbladder disease">Gallbladder</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Cholecystitis" title="Cholecystitis">Cholecystitis</a></li> <li><a href="/wiki/Gallstone" title="Gallstone">Gallstone / Cholelithiasis</a></li> <li><a href="/wiki/Cholesterolosis_of_gallbladder" title="Cholesterolosis of gallbladder">Cholesterolosis</a></li> <li><a href="/wiki/Adenomyomatosis" title="Adenomyomatosis">Adenomyomatosis</a></li> <li><a href="/wiki/Postcholecystectomy_syndrome" title="Postcholecystectomy syndrome">Postcholecystectomy syndrome</a></li> <li><a href="/wiki/Porcelain_gallbladder" title="Porcelain gallbladder">Porcelain gallbladder</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Bile_duct" title="Bile duct">Bile duct</a>/ <br /> Other <a href="/wiki/Biliary_tree" class="mw-redirect" title="Biliary tree">biliary tree</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Cholangitis" class="mw-redirect" title="Cholangitis">Cholangitis</a> <ul><li><a href="/wiki/Primary_sclerosing_cholangitis" title="Primary sclerosing cholangitis">Primary sclerosing cholangitis</a></li> <li><a href="/wiki/Secondary_sclerosing_cholangitis" title="Secondary sclerosing cholangitis">Secondary sclerosing cholangitis</a></li> <li><a href="/wiki/Ascending_cholangitis" title="Ascending cholangitis">Ascending</a></li></ul></li> <li><a href="/wiki/Cholestasis" title="Cholestasis">Cholestasis</a>/<a href="/wiki/Mirizzi%27s_syndrome" title="Mirizzi's syndrome">Mirizzi's syndrome</a></li> <li><a href="/wiki/Biliary_fistula" title="Biliary fistula">Biliary fistula</a></li> <li><a href="/wiki/Haemobilia" title="Haemobilia">Haemobilia</a></li></ul> <ul><li><i><a href="/wiki/Common_bile_duct" title="Common bile duct">Common bile duct</a></i> <ul><li><a href="/wiki/Choledocholithiasis" class="mw-redirect" title="Choledocholithiasis">Choledocholithiasis</a></li> <li><a href="/wiki/Biliary_dyskinesia" title="Biliary dyskinesia">Biliary dyskinesia</a></li></ul></li> <li><a href="/wiki/Sphincter_of_Oddi_dysfunction" title="Sphincter of Oddi dysfunction">Sphincter of Oddi dysfunction</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Pancreatic_disease" title="Pancreatic disease">Pancreatic</a></th><td class="navbox-list-with-group navbox-list navbox-even" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Pancreatitis" title="Pancreatitis">Pancreatitis</a> <ul><li><a href="/wiki/Acute_pancreatitis" title="Acute pancreatitis">Acute</a></li> <li><a href="/wiki/Chronic_pancreatitis" title="Chronic pancreatitis">Chronic</a></li> <li><a href="/wiki/Hereditary_pancreatitis" title="Hereditary pancreatitis">Hereditary</a></li> <li><a href="/wiki/Pancreatic_abscess" title="Pancreatic abscess">Pancreatic abscess</a></li></ul></li> <li><a href="/wiki/Pancreatic_pseudocyst" title="Pancreatic pseudocyst">Pancreatic pseudocyst</a></li> <li><a href="/wiki/Exocrine_pancreatic_insufficiency" title="Exocrine pancreatic insufficiency">Exocrine pancreatic insufficiency</a></li> <li><a href="/wiki/Pancreatic_fistula" title="Pancreatic fistula">Pancreatic fistula</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Other</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th id="Hernia" scope="row" class="navbox-group" style="width:1%"><a href="/wiki/Hernia" title="Hernia">Hernia</a></th><td class="navbox-list-with-group navbox-list navbox-odd" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Diaphragmatic_hernia" title="Diaphragmatic hernia">Diaphragmatic</a> <ul><li><a href="/wiki/Congenital_diaphragmatic_hernia" title="Congenital diaphragmatic hernia">Congenital</a></li></ul></li> <li><a href="/wiki/Hiatus_hernia" class="mw-redirect" title="Hiatus hernia">Hiatus</a></li></ul> <ul><li><a href="/wiki/Inguinal_hernia" title="Inguinal hernia">Inguinal</a> <ul><li><a href="/wiki/Indirect_inguinal_hernia" class="mw-redirect" title="Indirect inguinal hernia">Indirect</a></li> <li><a href="/wiki/Direct_inguinal_hernia" class="mw-redirect" title="Direct inguinal hernia">Direct</a></li></ul></li> <li><a href="/wiki/Umbilical_hernia" title="Umbilical hernia">Umbilical</a></li> <li><a href="/wiki/Femoral_hernia" title="Femoral hernia">Femoral</a></li> <li><a href="/wiki/Obturator_hernia" title="Obturator hernia">Obturator</a></li> <li><a href="/wiki/Spigelian_hernia" title="Spigelian hernia">Spigelian</a></li></ul> <ul><li><i><a href="/wiki/Lumbar_hernia" class="mw-redirect" title="Lumbar hernia">Lumbar</a></i> <ul><li><a href="/wiki/Petit%27s_hernia" title="Petit's hernia">Petit's</a></li> <li><a href="/wiki/Grynfeltt%E2%80%93Lesshaft_hernia" title="Grynfeltt–Lesshaft hernia">Grynfeltt–Lesshaft</a></li></ul></li></ul> <ul><li><i>Undefined location</i> <ul><li><a href="/wiki/Incisional_hernia" title="Incisional hernia">Incisional</a></li> <li><a href="/wiki/Internal_hernia" title="Internal hernia">Internal hernia</a></li> <li><a href="/wiki/Richter%27s_hernia" title="Richter's hernia">Richter's</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" 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