Cirrhosis complications

Question 1

Hepatic encephalopathy

What are the grades of HE

Answer 1

1. Change in sleep cycle
2. Disorientation, lethargic\ Flapping tremor
3. Confusion\ Somnolence
4. Coma

Question 2

Hepatic encephalopathy

Pathophysiology of HE

Answer 2

1. Failure of the liver to detoxify NH3
2. Lead to cerebral edema, decrease O consumption and increase ROS.
3. This will lead to mental disturbance.

Question 3

Hepatic encephalopathy

Etiology of HE

Answer 3

1. Non-compliance to medications.
2. Using other med’s: sedative agents.
3. Constipation.
4. Metabolic: Hypokalemia or Hyponatremia or alkalosis
5. Hypovolemia: GI bleeding or dehydration.
6. TIPS Or PVT
7. Infections.

Question 4

Hepatic encephalopathy

How to diagnose HE?

Answer 4

• Clinical diagnosis.
• Ammonia level is not specific.

Question 5

Hepatic encephalopathy

Management of HE

Answer 5

1) Treat underlying cause.
2) Maintain nutrition
2) Lactoluse.
3) Rifaximin (not first-line)
4) Polythelin glycol (PEG) Alternative option

Question 6

Hepatic encephalopathy

How much protein to give in patient with HE?

Answer 6

• Protein 1 to 1.5 g\Kg\Day
• Energy intake 20 to 40 kcal\Kg

Question 7

Hepatic encephalopathy

Mechanism of lactoluse and rifaximin

Answer 7

Lactoluse: Colon acidification (NH3 to NH4)
Rifaximin: decrease NH3 production by decreasing gut bacteria production

Question 8

Hepatic encephalopathy

Dose of rifaximin?

Answer 8

550 mg BID

Question 9

Hepatic encephalopathy

What is the target Bowel motion in patient with HE?

Answer 9

In patient: 3 to 5
Outpatient: 2 to 3

Question 10

Hepatic encephalopathy

In treating HE. Goal of K?

Answer 10

More than 4 + avoid alkalosis

Question 11

Hepatic encephalopathy

When to start rifaximin?

Answer 11

1) Grade 3 to 4 HE
2) Second episode of HE

Used in conjunction with lactoluse.