Hepatic encephalopathy - Revision history

Danbot: Add MedicationDose entry (lactulose) with SMW annotations

2026-03-20T18:39:37Z

Add MedicationDose entry (lactulose) with SMW annotations

← Older revision		Revision as of 18:39, 20 March 2026
Line 87:		Line 87:
	*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.		*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.



			==Medication Dosing==
			{{MedicationDose
			\| drug = Lactulose
			\| dose = 20g PO or 300mL in 700mL H2O retention enema x 30min
			\| route = PO or rectal
			\| context = First-line treatment for hepatic encephalopathy
			\| indication = Hepatic encephalopathy
			\| population = Adult
			}}

	==Disposition==		==Disposition==

Ostermayer: Prepared the page for translation

2026-01-04T22:59:24Z

Prepared the page for translation

← Older revision		Revision as of 22:59, 4 January 2026
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			<languages/>
			<translate>

	==Background==		==Background==

	*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		*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]]		**[[Special:MyLanguage/GI Bleed\|GI Bleed]]
	**Excess dietary intake of protein		**Excess dietary intake of protein
	**[[Infection]] (e.g. [[SBP]])		**[[Special:MyLanguage/Infection\|Infection]] (e.g. [[Special:MyLanguage/SBP\|SBP]])
	**[[Hypokalemia]]		**[[Special:MyLanguage/Hypokalemia\|Hypokalemia]]
	**[[Metabolic Alkalosis]]		**[[Special:MyLanguage/Metabolic Alkalosis\|Metabolic Alkalosis]]
	**[[Constipation]]		**[[Special:MyLanguage/Constipation\|Constipation]]
	*[[Dehydration]]		*[[Special:MyLanguage/Dehydration\|Dehydration]]
	**[[Vomiting]]		**[[Special:MyLanguage/Vomiting\|Vomiting]]
	**[[Diuretics]]		**[[Special:MyLanguage/Diuretics\|Diuretics]]
	*Drugs		*Drugs
	**[[Opioids]]		**[[Special:MyLanguage/Opioids\|Opioids]]
	**[[Benzodiazepines]] (including [[benzodiazepine withdrawal\|withdrawal]])		**[[Special:MyLanguage/Benzodiazepines\|Benzodiazepines]] (including [[Special:MyLanguage/benzodiazepine withdrawal\|withdrawal]])
	**[[ETOH]] (including withdrawal)		**[[Special:MyLanguage/ETOH\|ETOH]] (including withdrawal)


	==Clinical Features==		==Clinical Features==

	[[File:Jaundice08.jpg\|thumb\|Jaundice of the skin]]		[[File:Jaundice08.jpg\|thumb\|Jaundice of the skin]]
	[[File:SpiderAngioma.jpg\|thumb\|Spider angioma]]		[[File:SpiderAngioma.jpg\|thumb\|Spider angioma]]
	[[File:Hepaticfailure.jpg\|thumb\|\|Ascites secondary to [[cirrhosis]].]]		[[File:Hepaticfailure.jpg\|thumb\|\|Ascites secondary to [[Special:MyLanguage/cirrhosis\|cirrhosis]].]]

	===Stages===		===Stages===

	*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, marked disorientation, inability to follow commands, extensor plantar reflexes		*Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
	*Stage IV - Coma		*Stage IV - Coma


	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Subdural Hematoma]]
	*[[Hypoglycemia]]		*[[Special:MyLanguage/Subdural Hematoma\|Subdural Hematoma]]
	*[[Wernicke-Korsakoff Syndrome]]		*[[Special:MyLanguage/Hypoglycemia\|Hypoglycemia]]
	*[[hypernatremia\|Hyper]]/[[hyponatremia]]		*[[Special:MyLanguage/Wernicke-Korsakoff Syndrome\|Wernicke-Korsakoff Syndrome]]
	*[[Benzodiazepine Overdose]] (decreased hepatic clearance)		*[[Special:MyLanguage/hypernatremia\|Hyper]]/[[Special:MyLanguage/hyponatremia\|hyponatremia]]
	*[[Renal Failure]]		*[[Special:MyLanguage/Benzodiazepine Overdose\|Benzodiazepine Overdose]] (decreased hepatic clearance)
	*[[Sepsis]]		*[[Special:MyLanguage/Renal Failure\|Renal Failure]]
			*[[Special:MyLanguage/Sepsis\|Sepsis]]


	==Evaluation==		==Evaluation==


	===Workup===		===Workup===

	*CBC		*CBC
	*Chemistry		*Chemistry
	*Ammonia level		*Ammonia level
	*[[LFTs]]		*[[Special:MyLanguage/LFTs\|LFTs]]
	*PT/PTT		*PT/PTT
	*[[Urinalysis]]		*[[Special:MyLanguage/Urinalysis\|Urinalysis]]
	*[[CXR]]		*[[Special:MyLanguage/CXR\|CXR]]
	*[[Head CT]]		*[[Special:MyLanguage/Head CT\|Head CT]]
	*[[Paracentesis]] in patient with ascites (rule out [[SBP]])		*[[Special:MyLanguage/Paracentesis\|Paracentesis]] in patient with ascites (rule out [[Special:MyLanguage/SBP\|SBP]])
	*Consider [[LP]]		*Consider [[Special:MyLanguage/LP\|LP]]


	===Evaluation===		===Evaluation===

	*Full neuro exam including asterixis		*Full neuro exam including asterixis
	*[[Elevated ammonia]] level. Ammonia is not predictive of severity of disease.		*[[Special:MyLanguage/Elevated ammonia\|Elevated ammonia]] level. Ammonia is not predictive of severity of disease.
	*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 [[Special:MyLanguage/GI bleed\|GI bleed]] or [[Special:MyLanguage/hypovolemia\|hypovolemia]]


	==Management==		==Management==
	*[[Lactulose]] 20g PO or (300mL in 700cc H2O retention enema x30min)
			*[[Special:MyLanguage/Lactulose\|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
Line 66:		Line 86:
	*Rifaximin is second line.		*Rifaximin is second line.
	*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.		*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.


	==Disposition==		==Disposition==

	*Discharge stage I if good resources.		*Discharge stage I if good resources.
	*Stage II will need admission unless known encephalopathy and who is otherwise well.		*Stage II will need admission unless known encephalopathy and who is otherwise well.
	*Stage III and IV admission +/- ICU or obs bed.		*Stage III and IV admission +/- ICU or obs bed.


	==Patient Information==		==Patient Information==

	[http://www.nlm.nih.gov/medlineplus/ency/article/000302.htm Hepatic Encephalopathy] (Medline Plus)		[http://www.nlm.nih.gov/medlineplus/ency/article/000302.htm Hepatic Encephalopathy] (Medline Plus)


	==See Also==		==See Also==
	*[[Acute hepatic failure]]
			*[[Special:MyLanguage/Acute hepatic failure\|Acute hepatic failure]]


	==References==		==References==

	<references/>		<references/>
	[[Category:GI]]		[[Category:GI]]
			</translate>

Rossdonaldson1: /* Clinical Features */

2021-10-23T12:57:57Z

Clinical Features

← Older revision		Revision as of 12:57, 23 October 2021
Line 22:		Line 22:

	==Clinical Features==		==Clinical Features==
			[[File:Jaundice08.jpg\|thumb\|Jaundice of the skin]]
			[[File:SpiderAngioma.jpg\|thumb\|Spider angioma]]
			[[File:Hepaticfailure.jpg\|thumb\|\|Ascites secondary to [[cirrhosis]].]]
	===Stages===		===Stages===
	*Stage I - General apathy		*Stage I - General apathy

Dcpinzonc: /* Evaluation */

2021-10-18T14:37:14Z

Evaluation

← Older revision		Revision as of 14:37, 18 October 2021
Line 51:		Line 51:

	===Evaluation===		===Evaluation===
	*[[Elevated ammonia]] level		*Full neuro exam including asterixis
			*[[Elevated ammonia]] level. Ammonia is not predictive of severity of disease.
	*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]]

Dcpinzonc: /* Management */

2021-10-18T14:35:26Z

Management

← Older revision		Revision as of 14:35, 18 October 2021
Line 59:		Line 59:
	**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

			*Rifaximin is second line.
			*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.

	==Disposition==		==Disposition==

Dcpinzonc: /* Disposition */

2021-10-18T14:33:28Z

Disposition

← Older revision		Revision as of 14:33, 18 October 2021
Line 61:		Line 61:

	==Disposition==		==Disposition==
	*Discharge stage I or II ~~with~~ known encephalopathy and who is otherwise well		*Discharge stage I if good resources.
			*Stage II will need admission unless known encephalopathy and who is otherwise well.
			*Stage III and IV admission +/- ICU or obs bed.

	==Patient Information==		==Patient Information==

ClaireLewis: /* Evaluation */

2021-04-21T05:04:17Z

Evaluation

← Older revision		Revision as of 05:04, 21 April 2021
Line 51:		Line 51:

	===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]]

Rossdonaldson1: /* See Also */

2020-06-04T18:46:55Z

ClaireLewis at 21:02, 29 September 2019

2019-09-29T21:02:02Z

← Older revision		Revision as of 21:02, 29 September 2019
Line 9:		Line 9:
	**[[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)

Line 32:		Line 32:
	*[[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]]
Line 42:		Line 42:
	*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]]

Line 53:		Line 53:
	*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==
Line 61:		Line 61:

	==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==

Aganapathy: /* Stages */

2018-01-21T08:11:06Z

Stages

← Older revision		Revision as of 08:11, 21 January 2018
Line 25:		Line 25:
	*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

← Older revision		Revision as of 18:46, 4 June 2020
Line 67:		Line 67:

	==See Also==		==See Also==
			*[[Acute hepatic failure]]

	==References==		==References==
	<references/>		<references/>
	[[Category:GI]]		[[Category:GI]]