Difference between revisions of "Hepatic encephalopathy"

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*Diagnosis of exclusion
 
*Diagnosis of exclusion
 
*Due to accumulation of nitrogenous waste products normally metabolized by the liver
 
*Due to accumulation of nitrogenous waste products normally metabolized by the liver
 +
*Increased metabolism of ammonia to glutamine in CNS
 
*Spectrum of illness ranges from chronic fatigue to acute lethargy
 
*Spectrum of illness ranges from chronic fatigue to acute lethargy
  
==Precipitants==
+
===Precipitants===
#Increased ammonia production, absorption or entry into brain:
+
*Increased ammonia production, absorption or entry into brain:
##GI bleed
+
**[[GI Bleed]]
##Excess dietary intake of protein
+
**Excess dietary intake of protein
##Infection
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**[[Infection]] (e.g. [[SBP]])
##Hypokalemia
+
**[[Hypokalemia]]
##Metabolic alkalosis
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**[[Metabolic Alkalosis]]
##Constipation
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**[[Constipation]]
#Dehydration
+
*[[Dehydration]]
##Vomiting
+
**[[Vomiting]]
##Diuretics
+
**[[Diuretics]]
#Drugs
+
*Drugs
##Opioids  
+
**[[Opioids]]
##Benzodiazepines (including withdrawal)
+
**[[Benzodiazepines]] (including [[benzodiazepine withdrawal|withdrawal]])
##ETOH (including withdrawal)
+
**[[ETOH]] (including withdrawal)
  
==Stages==
+
==Clinical Features==
#Stage I - General apathy
+
===Stages===
#Stage II - Lethargy, drowsiness, variable orientation, asterixis
+
*Stage I - General apathy
#Stage III - Stupor with hyperreflexia, extensor plantar reflexes
+
*Stage II - Lethargy, drowsiness, variable orientation, asterixis
#Stage IV - Coma
+
*Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
 +
*Stage IV - Coma
  
==DDx==
+
==Differential Diagnosis==
#Subdural hematoma
+
*[[Subdural Hematoma]]
#Hypoglycemia
+
*[[Hypoglycemia]]
#Wernicke-Korsakoff syndrome
+
*[[Wernicke-Korsakoff Syndrome]]
#Hyper/hyponatremia
+
*[[hypernatremia|Hyper]]/[[hyponatremia]]
#Benzodiazepine overdose (decreased hepatic clearance)
+
*[[Benzodiazepine Overdose]] (decreased hepatic clearance)
#Renal failure
+
*[[Renal Failure]]
#Sepsis
+
*[[Sepsis]]
  
==Work-up==
+
==Evaluation==
 +
===Workup===
 +
*CBC
 +
*Chemistry
 +
*Ammonia level
 +
*[[LFTs]]
 +
*PT/PTT
 +
*[[Urinalysis]]
 +
*[[CXR]]
 +
*[[Head CT]]
 +
*[[Paracentesis]] in patient with ascites (rule out [[SBP]])
 +
*Consider [[LP]]
 +
 
 +
===Evaluation===
 +
*[[Elevated ammonia]] level
 
*History of any new medications or toxin ingestion
 
*History of any new medications or toxin ingestion
*Focus exam on looking for signs of GI bleed or hypovolemia
+
*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==
+
==Management==
#Lactulose 20mg PO or (300mL in 700cc H2O retention enema x30min)
+
*[[Lactulose]] 20g PO or (300mL in 700cc H2O retention enema x30min)
##In colon degrades into lactic acid: acidic environment traps ammonia
+
**In colon degrades into lactic acid: acidic environment traps ammonia
##Also inhibits ammonia production in gut wall
+
**Also inhibits ammonia production in gut wall
  
 
==Disposition==
 
==Disposition==
Discharge
+
*Discharge stage I or II with known encephalopathy and who is otherwise well
*Stage I or II w/ known ecephalopathy and who is otherwise well
 
  
 
==Patient Information==
 
==Patient Information==
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==See Also==
 
==See Also==
 +
*[[Acute hepatic failure]]
  
==Source==
+
==References==
Tintinalli
+
<references/>
 
 
 
[[Category:GI]]
 
[[Category:GI]]

Latest revision as of 05:04, 21 April 2021

Background

  • Diagnosis of exclusion
  • Due to accumulation of nitrogenous waste products normally metabolized by the liver
  • Increased metabolism of ammonia to glutamine in CNS
  • Spectrum of illness ranges from chronic fatigue to acute lethargy

Precipitants

Clinical Features

Stages

  • Stage I - General apathy
  • Stage II - Lethargy, drowsiness, variable orientation, asterixis
  • Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
  • Stage IV - Coma

Differential Diagnosis

Evaluation

Workup

Evaluation

Management

  • Lactulose 20g 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 with known encephalopathy and who is otherwise well

Patient Information

Hepatic Encephalopathy (Medline Plus)

See Also

References