Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA.
Recent advances have led to a greater understanding of how alcohol alters the brain, both in acute stages (intoxication and alcohol withdrawal) and in chronic misuse. This review focuses on the current understanding of how alcohol affects the brain in cirrhosis patients with and without hepatic encephalopathy. Chronic alcohol use is associated with nutritional deficiencies, dementia, cirrhosis, and decompensating events such as hepatic encephalopathy. Direct toxicity on brain tissue, induction of neuro-inflammation, and alcohol's alterations of the gut microbiome are possible mechanisms for the clinical features of hepatic encephalopathy associated with alcohol use. Acute management of the alcoholic cirrhosis patient with altered mental status should focus on ruling out other causes, best intensive care, and use of gut-based therapies such as lactulose and rifaximin. Long term management centers on optimizing treatment of concurrent mood disorders, nutritional support, and medical management of complications associated with cirrhosis. Future studies are needed to clarify mechanisms of brain injury in concomitant alcohol misuse and HE in addition to designing treatment interventions in order to improve outcomes in these patients.