Hepatic encephalopathy: Difference between revisions
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*Spectrum of illness ranges from chronic fatigue to acute lethargy | *Spectrum of illness ranges from chronic fatigue to acute lethargy | ||
== | ==Precipitants== | ||
# | #Increased ammonia production, absorption or entry into brain: | ||
##GI bleed | ##GI bleed | ||
## | ##Excess dietary intake of protein | ||
# | ##Infection | ||
## | ##Hypokalemia | ||
## | ##Metabolic alkalosis | ||
## | ##Constipation | ||
#Dehydration | |||
##Vomiting | |||
##Diuretics | |||
#Drugs | |||
##Opioids | |||
##Benzodiazepines (including withdrawal) | |||
##ETOH (including withdrawal) | |||
==Stages== | ==Stages== | ||
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#Renal failure | #Renal failure | ||
#Sepsis | #Sepsis | ||
==Work-up== | |||
*History of any new medications or toxin ingestion | |||
*Focus exam on looking for signs of GI bleed or hypovolemia | |||
*Chemistry (look for metabolic and electrolyte derrangements) | |||
*Search for source of infection: | |||
**CBC, UA, CXR, Paracentesis in pt with ascites (r/o SBP) | |||
**LP if indicated | |||
*Head CT | |||
==Treatment== | ==Treatment== |
Revision as of 04:57, 5 March 2014
Background
- Diagnosis of exclusion
- Due to accumulation of nitrogenous waste products normally metabolized by the liver
- Spectrum of illness ranges from chronic fatigue to acute lethargy
Precipitants
- Increased ammonia production, absorption or entry into brain:
- GI bleed
- Excess dietary intake of protein
- Infection
- Hypokalemia
- Metabolic alkalosis
- Constipation
- Dehydration
- Vomiting
- Diuretics
- Drugs
- Opioids
- Benzodiazepines (including withdrawal)
- ETOH (including withdrawal)
Stages
- Stage I - General apathy
- Stage II - Lethargy, drowsiness, variable orientation, asterixis
- Stage III - Stupor with hyperreflexia, extensor plantar reflexes
- Stage IV - Coma
DDx
- Subdural hematoma
- Hypoglycemia
- Wernicke-Korsakoff syndrome
- Hyper/hyponatremia
- Benzodiazepine overdose (decreased hepatic clearance)
- Renal failure
- Sepsis
Work-up
- History of any new medications or toxin ingestion
- Focus exam on looking for signs of GI bleed or hypovolemia
- Chemistry (look for metabolic and electrolyte derrangements)
- Search for source of infection:
- CBC, UA, CXR, Paracentesis in pt with ascites (r/o SBP)
- LP if indicated
- Head CT
Treatment
- Lactulose 20mg PO or (300mL in 700cc H2O retention enema x30min)
- In colon degrades into lactic acid: acidic environment traps ammonia
- Also inhibits ammonia production in gut wall
Disposition
Discharge
- Stage I or II w/ known ecephalopathy and who is otherwise well
Patient Information
Hepatic Encephalopathy (Medline Plus)
See Also
Source
Tintinalli