20.7.2013 Flashcards by Rakesh durai

Precipitating factors for hepatic encephalopathy

Hypokalemia
Alkalosis(diarrhoea,diuretics)
Constipation
High protein diet
SBP
Opioids 
Sedative hypnotics
Hematemesis
Shunt,TIPS
ALF
progressive hepatocellular dysfunction

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Substances elevated in hepatic encephalopathy

Ammonia
False Neurotransmitters
Mercaptans
Myoinositol
Neurosteroids
  allopregnanenolone
  Tetrahydrodeoxycorticosterone

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First sign and symptom of hepatic encephalopathy

Sign-constructional apraxia

Symptom-altered sleep pattern

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Dietary management in hepatic encephalopathy

Replacement of animal protein by vegetable protein

Diet rich in branched chain amino acids

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Goal of lactulose therapy

2-3 loose stools per day

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Side effects of neomycin

Renal toxicity

Ototoxicity

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Side effects of metronidazole

Peripheral neuropathy

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Trace mineral supplement helpful in hepatic encephalopathy

Zinc

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Effectiveness of beta-blocker therapy

25% reduction in resting pulse rate

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Calculation of Hct from Hb

Hb*3

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Neck flexors

Strap muscles

Sternocleidomastoid

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Neck extensors

Longus colli

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Asterexis is seen in which grades of hepatic encephalopathy

Grade 2 and 3

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Grade 1 hepatic encephalopathy

Sleep reversal
Mild confusion
Irritability
Tremor

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Grade 2 hepatic encephalopathy

Disorientation
Lethargy
Inappropriate behaviour
Asterixis

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Grade 3 hepatic encephalopathy

Severe confusion
Somnolence
Aggressive behaviour
Asterixis

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EEG in hepatic encephalopathy

Slow,high amplitude,triphasic waves

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Role of blood ammonia level in hepatic encephalopathy

Neither sensitive and nor specific

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Initial dose of lactulose

15-45ml bd or qid

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Contraindications to oral lactulose

Ileus

Bowel obstruction

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Dose of rifaximin

400mg PO tid

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Structures affected in hepatic encephalopathy

Cerebellum

Basal ganglia

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Causes of elevated blood ammonia level

GI bleeding
Urea cycle disorders
Proline metabolism disorders
Diuretics
Alcohol
Narcotics
Valproate
CKD
Cigarette 
Muscle exertion and ischemia
High body temperature 
Tourniquet use while blood sampling
High protein diet

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Role of arterial ammonia level

Elevated levels(more than 150mg/dl) are predictive for cerebral edema and brain herniation in acute liver failure

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Name of grading system of hepatic encephalopathy

West haven

Highly specific test for diagnosis of hepatic encephalopathy

PSET | portosystemic encephalopathy syndrome test

Neuromuscular findings in Grade 1 hepatic encephalopathy

Tremor | Incoordination

Neuromuscular findings in grade 2 hepatic encephalopathy

Asterixis Ataxic gait Slow and slurred speech

Neuromuscular findings in grade 3 hepatic encephalopathy

``` Muscular rigidity Clonus Nystagmus Babinski Hyporeflexia ```

Latest tests in hepatic encephalopathy

Critical flicker frequency test MRS TAPIR(MR T1 mapping with partial inversion recovery)

Indication for lactulose enema in hepatic encephalopathy

Pts at risk of aspiration

First line agents in Rx of hepatic encephalopathy

Non absorbable disaccharides

Rx of mild hepatic encephalopathy in pts with cirrhosis and adult onset diabetes

Acarbose | Increases saccharolytic to proteolytic bacteria ratio

Drugs that enhance ammonia excretion in urine

Sodium benzoate Sodium phenylbutyrate Sodium phenylacetate

Why zinc is beneficial in hepatic encephalopathy?

Zinc increases the activity of Ornithine transcarbomylase

Artificial liver

MARS | molecular adsorbant recirculating system

Drug useful in grade 3 and 4 hepatic encephalopathy

Flumazenil

Amino acids useful in Rx of hepatic encephalopathy

LOLA L-Ornithine L-Aspartate Efficacy comparable to lactulose

What is MARS?

Extra corporeal albumin dialysis

Subtle signs of hepatic encephalopathy are seen in _____ % of pts with cirrhosis

Diff btw hepatic encephalopathy due to ALF and cirrhosis

Brain Edema plays a prominent role in HE due to ALF

Categories of hepatic encephalopathy

Type A- ALF Type B- portosystemic Bypass without hepatocellular disease Type C- cirrhosis

Histologic change in hepatic encephalopathy in cirrhosis

Alzheimer's type 2 astrocytosis(absent in ALF)

Neurotoxic substances in hepatic encephalopathy

``` Ammonia Manganese Short chain fatty acids False Neurotransmitters Mercaptans GABA ```

False Neurotransmitters

Octapamine Tyramine Betaphenylethanolamine

Important site of ammonia detoxification in cirrhosis

Skeletal muscle Contain Glutamine synthetase Skeletal muscle wasting in chronic cirrhosis increases hyperammonemia

Neurosteroid hypothesis in hepatic encephalopathy

Ammonia and manganese increase the expression of peripheral type Benzodiazepine receptor in astrocytes Stimulation of PTBR results in increased production of neurosteroids Neurosteroids stimulate GABA receptor

Grade zero hepatic encephalopathy

Covert hepatic encephalopathy

Causes for Asterixis

HE uremia Pulmonary insufficiency Barbiturate toxicity

Cause of fetor hepaticus

Mercaptans

MRI finding in hepatic encephalopathy

Hyperintensity of Globus pallidus due to manganese deposition

Rx of HE pt with severe agitation

Haloperidol

Why vegetable proteins are preferred in HE?

Contain dietary fibre | Decreased aromatic amino acids

Rifaximine?

Non absorbable derivative of rifampin

Use of rifaximine

Travellers diarrhoea | HE

Mechanism of action of LOLA

Stimulates urea cycle | Both aminoacids are substrates for glutamate transaminase,increased synthesis of glutamate

MOA of sodium benzoate

Combines with glycine to form hippurate which is excreted renally

MOA of sodium phenylbutyrate

Converted to phenylacetate which combines with Glutamine to form phenylacetylglutamine

Drug that can be given to improve sleep in hepatic encephalopathy pts

Hydroxyzine 25mg at bedtime

Urine osmolality in hyponatremia

Less than 100 mosm/L | Specific gravity less than 1.003