Hepatic encephalopathy: Difference between revisions
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*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, | **CBC, UA, CXR, paracentesis in pt with ascites (r/o SBP) | ||
**LP if indicated | **LP if indicated | ||
*Head CT | *Head CT | ||
==Treatment== | ==Treatment== |
Revision as of 04:58, 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