Hepatic encephalopathy

Short post now, what tips the patient with liver failure into hepatic encephalopathy?

ABCDEFGHI
A - Alcohol ( causes more liver destruction, acts as sedative too )
B - Bugs ( infection )
C - Constipation
D - Drugs ( sedatives )
E - Electrolytes ( hypoNa and hypoK )
F - Fluid ( spironolactone esp used to tx ascites )
G - GI bleeding
H - High protein diet ( gets converted to ammonia -> urea cycle )
I - Insufficiency of kidney ( hepatorenal syndrome )

A simpler way is to classify the causes:
Elevated ammonia and other toxic metabolites (ammonia is detoxified by entering the urea cycle in liver ) in blood
- 2 most important causes are GI bleeding and dehydration ( diuretics )
- Others - constipation and high protein diet
- Also remember TIPS ( transjugular intrahepatic portosystemic shunt ) that directly shunts the urea to the SVC bypassing the portal vein
- Hepatorenal syndrome also causes accumulation of toxic metabolites in the blood

Things that can suppress the brain ( neurons activity is already been suppressed by toxins due to ineffective liver metabolism - hypothesis states that GABA is the predominant neurotransmitter involved )
- Sedatives
- Alcohol

Infection is also a common cause ( esp SBP commonly happens in patients with tense ascites )