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== | ===Precipitants=== | ||
#Increased ammonia production, absorption or entry into brain: | #Increased ammonia production, absorption or entry into brain: | ||
##GI | ##[[GI Bleed]] | ||
##Excess dietary intake of protein | ##Excess dietary intake of protein | ||
##Infection | ##Infection | ||
##Hypokalemia | ##[[Hypokalemia]] | ||
##Metabolic | ##[[Metabolic Alkalosis]] | ||
##Constipation | ##Constipation | ||
#Dehydration | #Dehydration | ||
##Vomiting | ##[[Vomiting]] | ||
##Diuretics | ##Diuretics | ||
#Drugs | #Drugs | ||
##Opioids | ##Opioids | ||
##Benzodiazepines (including withdrawal) | ##Benzodiazepines (including withdrawal) | ||
##ETOH (including withdrawal) | ##[[ETOH]] (including withdrawal) | ||
==Stages== | ==Stages== | ||
| Line 27: | Line 27: | ||
==DDx== | ==DDx== | ||
#Subdural | #[[Subdural Hematoma]] | ||
#Hypoglycemia | #[[Hypoglycemia]] | ||
#Wernicke-Korsakoff | #[[Wernicke-Korsakoff Syndrome]] | ||
#Hyper/hyponatremia | #Hyper/[[hyponatremia]] | ||
#Benzodiazepine | #[[Benzodiazepine Overdose]] (decreased hepatic clearance) | ||
#Renal | #[[Renal Failure]] | ||
#Sepsis | #[[Sepsis]] | ||
==Work-up== | ==Work-up== | ||
| Line 41: | Line 41: | ||
*Search for source of infection: | *Search for source of infection: | ||
**CBC, UA, CXR, paracentesis in pt with ascites (r/o SBP) | **CBC, UA, CXR, paracentesis in pt with ascites (r/o SBP) | ||
**LP if indicated | **[[LP]] if indicated | ||
*Head CT | *Head CT | ||
Revision as of 17:09, 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
- UpToDate