Difference between revisions of "Hepatic encephalopathy"

(Management: changed lactulose from "mg" to "g.")
(Evaluation)
 
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**[[GI Bleed]]
 
**[[GI Bleed]]
 
**Excess dietary intake of protein
 
**Excess dietary intake of protein
**Infection
+
**[[Infection]] (e.g. [[SBP]])
 
**[[Hypokalemia]]
 
**[[Hypokalemia]]
 
**[[Metabolic Alkalosis]]
 
**[[Metabolic Alkalosis]]
**Constipation
+
**[[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)
  
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*Stage I - General apathy
 
*Stage I - General apathy
 
*Stage II - Lethargy, drowsiness, variable orientation, asterixis
 
*Stage II - Lethargy, drowsiness, variable orientation, asterixis
*Stage III - Stupor with hyperreflexia, extensor plantar reflexes
+
*Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
 
*Stage IV - Coma
 
*Stage IV - Coma
  
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*[[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]]
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*Chemistry
 
*Chemistry
 
*Ammonia level
 
*Ammonia level
*LFTs
+
*[[LFTs]]
 
*PT/PTT
 
*PT/PTT
 
*[[Urinalysis]]
 
*[[Urinalysis]]
 
*[[CXR]]
 
*[[CXR]]
*Head CT
+
*[[Head CT]]
*Paracentesis in patient with ascites (rule out [[SBP]])
+
*[[Paracentesis]] in patient with ascites (rule out [[SBP]])
 
*Consider [[LP]]
 
*Consider [[LP]]
  
 
===Evaluation===
 
===Evaluation===
*Elevated ammonia level
+
*[[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]]
  
 
==Management==
 
==Management==
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==Disposition==
 
==Disposition==
*Discharge stage I or II with known ecephalopathy and who is otherwise well
+
*Discharge stage I or II with known encephalopathy and who is otherwise well
  
 
==Patient Information==
 
==Patient Information==
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==See Also==
 
==See Also==
 +
*[[Acute hepatic failure]]
  
 
==References==
 
==References==
 
<references/>
 
<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