Clinical Manifestations
The earliest symptoms of hepatic encephalopathy include minor mental changes
and motor disturbances. The patient appears slightly confused, has alterations in
mood, becomes unkempt, and has altered sleep patterns. The patient tends to
sleep during the day and have restlessness and insomnia at night. As hepatic
encephalopathy progresses, the patient may be difficult to awaken. Asterixis (flapping tremor of the hands) may occur Simple tasks, such as handwriting, become difficult. A handwriting or drawing
sample (eg, star figure), taken daily, may provide graphic evidence of
progression or reversal of hepatic encephalopathy. Inability to reproduce a
simple figure. is referred to as constructional apraxia. In the early stages of hepatic encephalopathy, the deep tendon reflexes are
hyperactive; with worsening of hepatic encephalopathy, these reflexes disappear
and the extremities may become flaccid.Assessment and Diagnostic Findings
(EEG) shows generalized slowing, an increase in the amplitude of brain waves. Fetor hepaticus, a sweet, slightly fecal odor to the breath presumed to be of
intestinal origin may be noticed. The odor has also been described as similar to
that of freshly mowed grass, acetone, or old wine.