Decompensated Liver Disease Flashcards
Hepatic Encephalopathy
Hepatic encephalopathy may be seen in liver disease of any cause. The aetiology is not fully understood but is thought to include excess absorption of ammonia from bacterial breakdown of proteins in the gut
Features
confusion, altered GCS (see below)
hepatic flap
constructional apraxia: inability to draw a 5-pointed star
triphasic slow waves on EEG
raised ammonia level (not commonly measured anymore)
Grading of Hepatic Encephalopathy
Grading of hepatic encephalopathy Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
Hepatic Encephalopathy - Precipitating Factors
Precipitating factors infection e.g. spontaneous bacterial peritonitis GI bleed constipation drugs: sedatives, diuretics hypokalaemia renal failure increased dietary protein (uncommon)
Hepatic Encephalopathy Mx: Example Question
A 58-year-old man known to homeless services is brought to the emergency department by ambulance. He has been unwell with fevers and abdominal pain. He also reports increasing abdominal distension. His past medical history is significant for drug and alcohol dependency with hepatitic C and cirrhotic liver disease. He does not engage with medical services and takes no regular medications. An ascitic tap is performed that confirmed spontaneous bacterial peritonitis. He is admitted for IV antibiotics. You are called to see him by the nursing staff who report that his is agitated and restless during the night and drowsy during the day. On examination, he is unaware of the time or his current location and demonstrates asterixis.
Given the most likely diagnosis, what medical therapy should be instituted?
Lactulose - aiming for 3 stools/day, ceased after improvement Rifaximin - ceased after improvement Lactulose - aiming for 3 stools/day, continued after improvement > Lactulose and rifaximin - continued after improvement Lactulose and rifaximin - ceased after improvement
This patient has hepatic encephalopathy (HE). Infection (such as SBP) is a common trigger is patients with cirrhotic liver disease.
According to the American Association for the Study of Liver Diseases (AASLD)/European Association for the Study of the Liver (EASL) guidelines:
Lactulose is the first-choice agent for the treatment of hepatic encephalopathy and should continue for the prevention of recurrent episodes after initial episode.
Rifaximin as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after the second episode, and is approved by NICE.
Hepatic Encephalopathy Mx: Example Question
A 50-year-old male with a long history of cirrhosis secondary to chronic hepatitis C is brought to the emergency department by his partner with a 2-day history of increasing confusion.
He is drowsy but is rousable to voice. He is able to obey commands but is not oriented to where he is. Further examination revealed significant hepatic flap, multiple spider naevi on the torso, and mild abdominal distension with shifting dullness.
He is afebrile and his partner denies any history of recent infection.
His blood sugar level is 6.8 mmol/L
Which of the following should be started next?
Intravenous dextrose Regular intravenous haloperidol Oral rifaximin Intravenous midazolam > Regular oral lactulose
Hepatic encephalopathy is a common complication of liver cirrhosis. It is a neuropsychiatric syndrome of varying severity, ranging from disturbances in cognitive function or sleep-wake cycle to coma. Potential precipitants include infection (including septicaemia and spontaneous bacterial peritonitis), gastrointestinal bleeding, and metabolic or electrolyte disturbances, among others.
Management of hepatic encephalopathy entails supportive care and treating potential precipitating factors.
Hepatic encephalopathy is largely believed to occur from accumulation of ammonia in the blood stream due to the livers decreased ability to detoxify ammonia that is produced and transported from the gastrointestinal tract. One of the aim of treatment of hepatic encephalopathy is therefore to reduce the production and absorption of ammonia from the gastrointestinal tract. Lactulose is often used as the first line therapy. It is usually administered orally, but can be given per rectum if the patient is too drowsy to tolerate oral intake. Mechanisms of action of lactulose include the reduction of intestinal ammonia load through its action as a cathartic and its ability to inhibit ammoniagenic coliform bacteria by acidifying the colonic lumen.
Despite its common use in the treatment of hepatic encephalopathy, evidence regarding the efficacy of lactulose is however conflicting.
Oral rifaximin is sometimes used in cases of hepatic encephalopathy that are refractory to treatment with lactulose. It is also used to prevent hepatic encephalopathy in patients who have recurrence despite lactulose.
Decompensated Liver Disease - Causes
There are multiple causes of decompensation in the patient with liver disease:
Infection - pneumonia, spontaneous bacterial peritonitis, viruses (hepatitis B, C)
Drugs - paracetamol, anaesthetic agents
Toxin - alcohol, Amanita phalloides mushroom
Vascular - Budd-Chiari syndrome, vena-occlusive disease
Haemorrhage - Upper gastrointestinal bleed
Constipation
Decompensated Liver Disease - Signs
Signs: Asterixis Jaundice Hepatic encephalopathy Constructional apraxia (ask to draw a clock face)
Decompensated Liver Disease - Mx
Management:
Investigate to identify and exclude causes of decompensation - check blood tests, review drug chart, rectal examination for melaena and constipation, perform a septic screen.
Enhance nitrate clearance with phosphate enemas aiming for minimum three loose stools per day and lactulose to enhance binding of nitrate in the intestine.
Decompensated Liver Disease - Example Question
A 60-year-old man with Childs-Pugh C cirrhosis secondary to primary biliary cirrhosis presents to the emergency department with a cough. He is found to have pneumonia and is moved to an acute ward with treatment with intravenous antibiotics and fluids having been initiated.
You are called to see him the day after admission as his Glasgow coma scale score has decreased from 15 to 12.
His medications are Tazocin, spironolactone 150mg BD, paracetamol 500mg QDS PRN. He is apyrexial and examination reveals asterixis, right basal crepitations and faecal loading on digital rectal examination. There is mild ascites. No focal neurological signs are present.
Bloods show:
Hb 120 g/l Na+ 135 mmol/l Bilirubin 36 µmol/l
Platelets 120 * 109/l K+ 4.5 mmol/l ALP 140 u/l
WBC 15 * 109/l Urea 2.1 mmol/l ALT 150 u/l
Neuts 11.0 * 109/l Creatinine 70 µmol/l γGT 300 u/l
Lymphs 2.1 * 109/l Albumin 20 g/l
Eosin 0.1 * 109/l
CT head is reported as normal.
Blood glucose is normal.
An ascitic tap is performed with no organisms seen on microscopy.
What is the most approbate next step in management?
Increase spironolactone Switch antibiotics to Meropenem > Lactulose and phosphate enema Mannitol 10% glucose IV
Hepatic Encephalopathy - Mx
According to the American Association for the Study of Liver Diseases (AASLD)/European Association for the Study of the Liver (EASL) guidelines:
Lactulose is the first-choice agent for the treatment of hepatic encephalopathy and should continue for the prevention of recurrent episodes after initial episode.
Lactulose is often used as the first line therapy. It is usually administered orally, but can be given per rectum if the patient is too drowsy to tolerate oral intake. Mechanisms of action of lactulose include the reduction of intestinal ammonia load through its action as a cathartic and its ability to inhibit ammoniagenic coliform bacteria by acidifying the colonic lumen.
Rifaximin as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after the second episode, and is approved by NICE.
Oral rifaximin is sometimes used in cases of hepatic encephalopathy that are refractory to treatment with lactulose. It is also used to prevent hepatic encephalopathy in patients who have recurrence despite lactulose.
