Anaesthesiology Intensive Therapy
2014, vol. 46, no 1, 34–36
Hepatic encephalopathy in the course of alcoholic liver disease
— treatment options in the intensive care unit
Department of Anaesthesiology and Intensive Therapy, The Dr Wł. Biegański Regional Specialist
Hospital in Łódź, Poland
Hepatic encephalopathy occurs as a complication of alcoholic liver disease may require methods of dialysis available
in intensive care units. There is described the case of a 27-year-old patient with jaundice and hepatic encephalopathy
with long history of alcohol dependence and substance abuse. The patient was successfully treated using liver dialysis
method (Prometheus® system). Basing on this case it is possible to conclude that use of dialysis liver with Prometheus®
may be beneficial in patients with severe course of alcoholic liver disease.
Key words: intensive care; alcoholic liver disease, liver insufficiency; liver insufficiency, encephalopathy; liver dialysis
Anaesthesiology Intensive Therapy 2014, vol. 46, no 1, 34–36
Hepatic encephalopathy (HE) is a severe complication
of alcoholic liver disease (ALD) characterised by various
abnormalities, including cognitive impairment. In patients
with HE, the damaged liver cannot remove neurotoxic sub-
stances, which accumulate and enter the brain where they
can impair normal activity of neurotransmitters.
Treatment of patients with HE in the course of alcoholic
liver disease mostly involves measures to reduce blood
ammonia concentrations; in some cases, liver dialyses or
liver transplantations are performed. The management to
lower ammonia levels involves the supply of osmotically
active drugs (e.g. lactulose) and antibiotics (e.g. neomycin)
to decrease the production of ammonia in the gastrointe-
stinal tract. Another measure is to convert ammonia into
the substances harmless for the brain by administration of
Liver dialyses can be performed using special systems
available only in a few intensive care units. The techniques
applied include fractionated plasma separation and adsorp-
tion (FPSA) using the Prometheus® system [1–3], molecular
adsorbent recirculating system (MARS) [4, 5] or less compli-
cated single pass albumin dialysis (SPAD) [6–9] accessible
in each anaesthesiology and intensive therapy department
Only 10% of patients with alcoholic liver cirrhosis un-
dergo liver transplants despite the fact the alcoholic liver
diseases is one of the commonest indications for such pro-
cedures due to end-stage liver cirrhosis .
Patients with hepatic encephalopathy associated with
ALD are rarely seen in Polish anaesthesiology and intensive
therapy departments. They are usually treated in non-surgical
departments (of internal medicine, infectious diseases, hepa-
tic diseases, etc.) that are not prepared to perform FPSA, MARS
or even SPAD which is less demanding in terms of equipment.
The available treatment options for this group of pa-
tients seem not to be used to their full potential, especially
in severe clinical cases manifesting as a second- or higher-
-grade hepatic encephalopathy and/or total bilirubin con-
centration exceeding 15 mg/dl-1. Transfer of such patients
to anaesthesiology and intensive therapy departments for
liver dialyses may be a life-saving therapeutic option.
A 27-year-old patient with long-term history of alcohol
dependency and abuse of psychoactive substances was ad-
mitted to the Department of Internal Medicine due to severe
abdominal pain and yellowish discolouration of the skin. On
admission, the patient was under the influence of alcohol;
his blood ethanol concentration was 330 mg dL-1. The addi-
tional tests revealed total bilirubin of 12.6 mg dL-1, INR 1.62,
AST 323.6 U L-1, ALT 59.7 U L-1, GGTP 1406.5 U L-1, and serum
ammonia 196.8 µg dL-1. The abdominal CT scan disclosed “the
Mariusz Piechota, Hepatic encephalopathy
liver — markedly enlarged with features of steatosis, no focal
lesions, intra- and extrahepatic bile ducts — undilated, the
thin-walled gallbladder without calcifications”. The patient
was diagnosed with toxic liver damage, second-degree he-
patic coma, alcohol dependence syndrome, chronic atrophic
pancreatitis, cortico-subcortical atrophy of CNS, epilepsy, and
secondary anaemia. During the 15-day stay in the depart-
ment, the patient was initially agitated and subsequently
excessively sleepy. The drugs administered (dexamethasone,
lactulose, neomycin, spironolactone, propranolol, diazepam)
failed to improve his clinical condition despite the reduction
in concentrations of AST, ALT, GGTP and ammonia. Since the
patient’s general condition and liver function deteriorated
(total bilirubin 32.4 mg dL-1; INR 4.62), he was transferred to
the Department of Anaesthesiology and Intensive Therapy at
the Biegański District Specialist Hospital in Łódź to undergo
further treatment (liver dialyses, in particular).
On admission, the patient was conscious, drowsy, in lo-
gical contact; disturbances of consciousness were observed
periodically. The respiration and circulation were efficient.
His GCS, SOFA, APACHE II, and SAPS II scores were found to
be 14, 6, 13 and 17, respectively. Six FPSA procedures were
performed (Prometheus® 4008H, Fresenius Medical Care,
Germany) — on day 2, 3, 4, 5, 8 and 11 — which resulted in
temporary improvement of clinical condition and values of
biochemical parameters. During the first 4 days, the patient
experienced hallucinations, agitation and incoherence. Each
liver dialysis provoked temporarily increased tremor of the
hands and sleep disorders, which was associated with mild
Once the desired clinical condition was achieved (grade
0 hepatic encephalopathy, decrease in total bilirubin below
15 mg dL-1, proyhrombin index above 50%), the patient was
transported to the Department of Infectious and Hepatic
Severity of alcoholic liver disease is a derivative of time
and amount of alcohol consumed. The subsequent stages
of ALD include hepatic steatosis, hepatitis and cirrhosis. The
available data demonstrate a linear correlation between per
capita alcohol consumption and mortality attributable to
alcoholic liver disease.
Hepatic steatosis is entirely reversible provided the
alcohol consumption is reduced or discontinued. The di-
sease may develop even after short-term heavy alcohol
Alcoholic hepatitis may be acute, subacute or chronic. It
is caused not only by direct toxic effects of alcohol but also
by toxins from the intestinal bacteria that infiltrate the portal
system in excessive volumes. Acute alcoholic hepatitis most
commonly develops during the period of increased alcohol
consumption and may periodically manifest itself as liver
failure with full metabolic decompensation. Severe cases of
alcoholic hepatitis are characterized by poor general health
condition, jaundice, fever, high leucocytosis, tachycardia,
abdominal pain and confusion .
Cirrhosis occurs in less than 10% of alcohol abusers. The
risk of this form of ALD concerns individuals abusing alcohol
for at least 3–5 years. The majority of patients with alcoholic
cirrhosis do not survive the period of 10 years following
the diagnosis. In patients with decompensated cirrhosis,
a 5-year survival reaches 60% in those who stopped drinking
and drops below 30% in those continuing drinking .
Hepatic encephalopathy in alcoholic liver disease occurs
mainly in the most advanced stage of disease, i.e. in cirrho-
sis. However, it can also develop in earlier stages. Such cases
are usually a consequence of excessive alcohol consumption
before the onset of encephalopathy.
The use of dialyses to treat encephalopathy in the course
of alcoholic liver disease seems an interesting option. It
enables to reduce substantially the blood levels of various
toxic substances, including neurotoxins.
The most expensive yet the most effective method of
dialysis is fractionated plasma separation and adsorption
(FPSA) using the Prometheus® system .
FPSA ensures higher clearance of the majority of liver to-
xins, especially those strongly bound to serum albumins. The
Prometheus system supplements the 4008H haemodialy-
sis apparatus. In addition to haemodialysis procedures, it
enables extracorporeal removal of toxins from blood in
acute and chronic liver failure. Following the serum fractio-
nation, toxins that were originally bound to albumins are
removed thanks to the application of capillary filters with
albumin-permeable membranes and special adsorption
capsules. The procedure diagram is presented in Figure 1.
In severe clinical alcoholic liver disease, as the case de-
scribed, a series of liver dialyses ensuring time for regene-
ration of the hepatic parenchyma is optimal. Dialyses are
available in some intensive care units equipped with the
Prometheus® system. However, in line with the Polish pro-
visions of law, each anaesthesiology and intensive therapy
department should have at least one renal replacement
therapy device, which means that every patient from this
group can be treated with SPAD.
Liver transplants are performed in patients with alcoho-
lic cirrhosis in the end-stage chronic liver failure. Considering
average patient and graft survival rates as well as quality of
life of patients, the outcomes of transplantations for alco-
holic cirrhosis are comparable to or even better than those
after transplants due to other diseases .
In Poland, patients with alcoholic hepatitis are not quali-
fied for liver transplants. This is associated with the shortage of
organ donors and multiple organ complications of alcoholic
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Anaesthesiol Intensive Ther 2014, vol. 46, no 1, 34–36
Figure 1. Scheme of fractionated plasma separation and adsorption (FPSA)
disease that disqualify such patients (e.g. cardiomyopathy,
oesophageal cancer, pancreas failure, alcoholic characteropa-
thy). Moreover, in the majority of centres the inclusion crite-
rion is a 6-month alcohol abstinence prior to transplantation.
The use of the Prometheus® FPSA system is likely to
beneficially affect the course of exacerbations of alcoholic
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Mariusz Piechota, MD, PhD
Department of Anaesthesiology and Intensive Therapy,
The Dr Wł. Biegański Regional Specialist Hospital in Łódź, Poland
ul. Kniaziewicza 1/5; 91–347 Łódź, Poland
Filter of albumins