Updated: 4/9/2018

Hepatic Encephalopathy

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Snapshot
  • A 56-year-old man with a history of alcoholism and liver cirrohsis presents with new onset confusion and irritatibility. He was recently admitted for sepsis caused by pneumonia. On physical exam he has a flapping tremor, ascites, jaundice and is not oriented to time or place. 
Introduction
  • Also known as portosystemic encephalopathy
  • Reversible syndrome of impaired brain function caused by advanced liver failure
  • Liver dysfunction resulting in decreased detoxification capabilities and metabolic abnormalities
    • accumulation of ammonia (usually made by enterocytes)
    • activation of inhibitory neurotransmitters
      • gamma-aminobutyric acid
      • serotonin
    • impairment of excitatory neurotransmitters
      • glutamate
      • catecholamines
    • exact mechanism unknown
  • Factors that increase risk
    • sepsis
    • neuroinflammation
    • alterations in gut flora
    • transjugular intrahepatic portosystemic shunt (TIPS)
Presentation
  • Symptoms
    • irritability 
    • dementia
    • seizures
    • obtundation 
    • coma
  • Physical exam
    • hyperreflexia
    • asterixis (flapping of extended wrists)
  • Diagnosis
    • confirmed liver disease (LFT, ultrasound, biopsy)
    • neuropsychological testing
    • often hyperammonemia 
Treatment
  • Medical
    • lactulose (nonabsorbable sugar)
      • acidification of the gut lumen results in ammonia trapping and less reabsorption
      • side effect includes diarrhea
    • rifaximin (nonabsorbable antibiotic)
      • destruction of gut bacteria result in less conversion of dietary protein to ammonia
  • Diet
    • protein restriction to decrease ammonia related toxins
 

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