Brenda Khan
Hepatic encephalopathy is a neuropsychiatric condition caused by acute injury to the liver, which can be congenital or acquired. It is characterized by a build-up of toxins in the bloodstream, such as ammonia and manganese, which the liver fails to break down properly, leading to confusion and disorientation. The treatment of hepatic encephalopathy includes a special diet to lower toxin levels in the blood. While older literature recommended protein restriction, current evidence suggests that this is harmful and that a normal protein diet is safe and beneficial for patients with hepatic encephalopathy. A well-balanced diet with adequate caloric intake and the right composition of nutrients is crucial for managing this condition. Patients are advised to eat more frequent, smaller meals and include an evening snack rich in carbohydrates to improve glucose metabolism. In addition, reducing salt and alcohol intake is important for minimizing fluid retention.
Diet for Hepatic Encephalopathy
| Characteristics | Values |
|---|---|
| Number of Meals | Minimum 5 daily |
| Meal Size | Smaller portions |
| Bedtime Snack | Carbohydrate-rich |
| Calories | 2,000-3,000 per day |
| Protein | Plant-based, lean sources |
| Salt | Reduced intake |
| Alcohol | Stop or limit to one drink |
| Iron | Avoid if hemochromatosis |
| Copper | Avoid if Wilson's disease |
| Vitamins | Varies, may require supplements |
| Fibre | High dose |
| Fluids | May require diuretics |
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What You'll Learn
A diet for hepatic encephalopathy should be high in protein
A diet for hepatic encephalopathy (HE) should be high in protein, especially in patients who are underweight or malnourished. This is because malnutrition is a common complication of cirrhosis, with around 60% of cirrhosis patients being malnourished or cachexic.
Protein restriction was previously recommended for patients with HE. However, this has been debunked by recent studies, which have shown that a normal protein diet is safe for patients with HE. Furthermore, a protein-restricted diet can increase protein catabolism and lead to progressive and harmful protein depletion. Current evidence-based guidelines from organisations such as the International Society for Hepatic Encephalopathy (ISHEN) and the American Association for the Study of Liver Diseases (AASLD) recommend a daily protein intake of 1.2–1.5 g/kg.
For patients with acute encephalopathy, the initial dose of protein should be 0.5 g/kg/day, gradually increasing to 1.0-1.5 g/kg/day. Patients with chronic HE benefit from a diet containing plant-based proteins rather than animal-based proteins, as they are thought to be better tolerated. This is because vegetables are high in fibre, which promotes bacterial fermentation and decreases ammonia absorption from the gut. Additionally, dairy foods can be added to the diet as they are a good source of protein and are well tolerated by patients with cirrhosis and HE.
It is important to note that patients with severe HE (grades III and IV) may be exceptions and should restrict their protein intake. Additionally, a subset of cirrhotic patients with acute encephalopathy may benefit from a brief period of protein restriction. Patients should consult with a doctor or dietitian to receive specific advice regarding their diet.
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Carbohydrates should be the primary source of calories
Carbohydrates are essential for patients with liver disease and hepatic encephalopathy, constituting approximately 40-60% of their overall caloric intake. This is because the liver, in its functional state, plays a crucial role in regulating the metabolism of nutrients, their distribution, and appropriate use by the body. In the case of hepatic encephalopathy, a complex neuropsychiatric condition caused by acute injury to the liver, nutritional management becomes critical.
Additionally, all patients with encephalopathy should have a bedtime snack rich in complex carbohydrates to prevent nocturnal gluconeogenesis and improve glucose metabolism. This is an important aspect of managing hepatic encephalopathy, as malnutrition is common in these patients and is considered a significant factor affecting quality of life, outcome, and survival. Therefore, ensuring adequate caloric intake and a well-balanced diet is crucial.
It is important to note that nutritional requirements may vary according to the specific clinical situation, and patients should consult with their healthcare providers for personalized advice.
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Patients with cirrhosis must stop drinking alcohol
Patients with cirrhosis are often malnourished, with around 2 in 10 people with compensated cirrhosis and over 5 in 10 with decompensated cirrhosis suffering from malnutrition. This is due to a variety of factors, including insufficient food intake, loss of appetite, malabsorption, dyspepsia, and impaired metabolism of carbohydrates and lipids.
To prevent malnutrition, patients with cirrhosis are advised to eat a well-balanced diet with a particular focus on adequate energy (calories) and protein intake. Caloric recommendations range from 2,000 to 3,000 calories per day, with guidelines from nutrition societies suggesting 35 to 40 kcal/kg/day. Patients should eat little and often, having at least five meals a day, with a bedtime snack that is rich in carbohydrates to improve glucose metabolism.
Protein recommendations are between 1.2 and 1.5 g/kg/day. While older literature supported the use of protein-restricted diets in patients with hepatic encephalopathy, this has been debunked by more recent studies. Cardoba et al. (2004) showed that a protein-restricted diet increased protein catabolism, while Gheorghe et al. (2005) found that a high-calorie and high-protein diet improved hepatic encephalopathy in patients. Patients with acute encephalopathy should start with a lower protein intake of 0.5 g/kg/day, gradually increasing to 1.0-1.5 g/kg/day. Patients with chronic hepatic encephalopathy should opt for plant-based proteins over animal-based proteins.
In addition to adequate energy and protein intake, patients with cirrhosis should also reduce their salt and sodium intake to minimize fluid retention. They should opt for foods that are high in starchy carbohydrates, such as potatoes, bread, pasta, and rice, and choose chicken, turkey, fish, dairy, or plant-based options over red meat. They should also favor monounsaturated fats over saturated fats, with less than 10% of their energy intake coming from saturated fats.
It is important to note that patients with cirrhosis must stop drinking alcohol, as alcohol abuse is a common cause of cirrhosis. Alcohol consumption can further impair liver function and increase the risk of hepatic encephalopathy.
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Salt and sodium intake should be reduced to minimise fluid retention
A low-sodium diet can help manage fluid retention and reduce the risk of hyponatremia. This involves avoiding the addition of salt to meals and limiting the consumption of high-sodium foods. It is important to note that some products labelled as low-salt may contain other ingredients that should be consumed in moderation. It is always advisable to seek guidance from a registered dietitian or healthcare professional when making dietary changes to ensure adequate nutrition and avoid potential complications.
For patients with hepatic encephalopathy (HE), the relationship between serum sodium levels and the incidence of HE is complex. While hyponatremia is associated with the development of HE, the exact nature of this association is not yet fully understood. Some studies suggest that serum sodium levels may be a risk factor for HE in patients with cirrhosis and ascites. However, more research is needed to establish a clear conclusion.
It is worth noting that malnutrition is common in patients with cirrhosis and HE, and salt restriction may impact nutrient intake. Therefore, it is crucial to strike a balance between reducing salt and sodium intake to minimise fluid retention and ensuring adequate nutrition to prevent malnutrition, which can negatively affect survival and quality of life.
In summary, while salt and sodium intake reduction can help manage fluid retention, it should be approached with caution and under the guidance of healthcare professionals to ensure it complements medical treatment and does not contribute to malnutrition.
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Patients should eat 'little and often', also known as grazing
Eating little and often, or grazing, is a common approach for patients with cirrhosis or advanced liver disease. This is because malnutrition is common in patients with cirrhosis, especially those with hepatic encephalopathy (HE).
Grazing involves increasing the number of meals per day to a minimum of five, while decreasing the amount of food per meal. This approach can help patients get enough energy (calories) and protein without becoming malnourished or losing muscle mass. It can also help to manage fluid retention, as a full stomach can put pressure on the abdomen and increase fluid retention.
Grazing can also help patients with HE to manage their protein intake. While older literature supported the use of protein-restricted diets for patients with HE, this has since been debunked. Cardoba et al. (2004) showed that a protein-restricted diet increased protein catabolism, while a normal protein diet was safe for patients with HE. However, it is important to note that some patients with HE have a protein intolerance and must follow a low-protein diet to avoid the buildup of toxins in the liver. Patients with acute encephalopathy should start with a lower protein intake and gradually increase it.
In addition to grazing, patients with HE should also follow general dietary advice for cirrhosis, including eating a diet high in starchy carbohydrates, low in red meat, and higher in monounsaturated fats than saturated fats. They should also reduce their salt and alcohol intake to minimize fluid retention.
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Frequently asked questions
Hepatic encephalopathy is a neuropsychiatric condition caused by acute injury to the liver, or secondary to chronic liver disease. It can also be caused by portal vein confluence abnormalities, with or without portal hypertension.
Patients with hepatic encephalopathy should eat a diet rich in carbohydrates, with complex carbohydrates included in each meal. Carbohydrates should be the primary source of calories. Patients should also eat lean protein sources such as chicken (without skin) and fish.
Patients with hepatic encephalopathy should avoid foods high in salt and sodium, as well as raw seafood. Patients should also avoid sugary treats like cookies, cake, soda, and packaged baked goods.
Patients with hepatic encephalopathy are advised to increase the number of meals (minimum 5 daily), while decreasing the amount of food per meal. All patients with hepatic encephalopathy should also have a bedtime snack, rich in carbohydrates.
Patients with hepatic encephalopathy may benefit from taking supplements such as branched-chain amino acids (BCAA), which include valine, leucine, and isoleucine.
