Hepatic encephalopathy: Difference between revisions
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===Precipitants=== | ===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== | ==Clinical Features== | ||
===Stages=== | |||
*Stage I - General apathy | |||
*Stage II - Lethargy, drowsiness, variable orientation, asterixis | |||
*Stage III - Stupor with hyperreflexia, extensor plantar reflexes | |||
*Stage IV - Coma | |||
== | ==Differential Diagnosis== | ||
*[[Subdural Hematoma]] | |||
*[[Hypoglycemia]] | |||
*[[Wernicke-Korsakoff Syndrome]] | |||
*Hyper/[[hyponatremia]] | |||
*[[Benzodiazepine Overdose]] (decreased hepatic clearance) | |||
*[[Renal Failure]] | |||
*[[Sepsis]] | |||
== | ==Diagnosis== | ||
*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) | *Chemistry (look for metabolic and electrolyte derrangements) | ||
*Search for source of infection: | *Search for source of infection: | ||
**CBC, UA, CXR, paracentesis in | **CBC, UA, CXR, paracentesis in patient with ascites (r/o SBP) | ||
**[[LP]] if indicated | **[[LP]] if indicated | ||
*Head CT | *Head CT | ||
==Treatment== | ==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== | ==Disposition== | ||
Discharge | *Discharge stage I or II with known ecephalopathy and who is otherwise well | ||
==Patient Information== | ==Patient Information== | ||
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==See Also== | ==See Also== | ||
== | ==References== | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 12:37, 26 August 2015
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)
Clinical Features
Stages
- Stage I - General apathy
- Stage II - Lethargy, drowsiness, variable orientation, asterixis
- Stage III - Stupor with hyperreflexia, extensor plantar reflexes
- Stage IV - Coma
Differential Diagnosis
- Subdural Hematoma
- Hypoglycemia
- Wernicke-Korsakoff Syndrome
- Hyper/hyponatremia
- Benzodiazepine Overdose (decreased hepatic clearance)
- Renal Failure
- Sepsis
Diagnosis
- Ammonia level
- 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 patient 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 with known ecephalopathy and who is otherwise well
Patient Information
Hepatic Encephalopathy (Medline Plus)