Hepatic encephalopathy

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

Causes

1. Increase in nitrogenous waste
   1. GI bleed
   2. Protein load from large meal
2. Decreased hepatic metabolism
   1. Liver disease
   2. Alcohol withdrawal
   3. Sepsis

Stages

1. Stage I - General apathy
2. Stage II - Lethargy, drowsiness, variable orientation, asterixis
3. Stage III - Stupor with hyperreflexia, extensor plantar reflexes
4. Stage IV - Coma

DDx

1. Subdural hematoma
2. Hypoglycemia
3. Wernicke-Korsakoff syndrome
4. Hyper/hyponatremia
5. Benzodiazepine overdose (decreased hepatic clearance)
6. Renal failure
7. Sepsis

Treatment

1. Lactulose 20mg PO or (300mL in 700cc H2O retention enema x30min)
   1. In colon degrades into lactic acid: acidic environment traps ammonia
   2. Also inhibits ammonia production in gut wall

Disposition

Discharge

• Stage I or II w/ known ecephalopathy and who is otherwise well

Source

Tintinalli