Hepatic encephalopathy: Difference between revisions
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==Management== | ==Management== | ||
*[[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 | ||
Revision as of 04:47, 19 September 2017
Background
- Diagnosis of exclusion
- Due to accumulation of nitrogenous waste products normally metabolized by the liver
- Increased metabolism of ammonia to glutamine in CNS
- 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
Evaluation
Workup
- CBC
- Chemistry
- Ammonia level
- LFTs
- PT/PTT
- Urinalysis
- CXR
- Head CT
- Paracentesis in patient with ascites (rule out SBP)
- Consider LP
Evaluation
- Elevated ammonia level
- History of any new medications or toxin ingestion
- Focus exam on looking for signs of GI bleed or hypovolemia
Management
- Lactulose 20g 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)