Hepatic encephalopathy

Question 1

HE patho

Answer 1

Accumulation of toxins –> altered mentation

Question 2

Causes of HE in cirrhotic patients

Answer 2

Portal systemic shunting –> Decreased hepatic function - no ammonia metabolism

Question 3

Interpreting ammonia levels

Answer 3

Does not correlate to severity
Dichotomous diagnosis variable for confirming AMS
Elevated + AMS = HE
Elevated + no AMS = not HE
Do not need to recheck ammonia levels after treatment
Determine treatment success based on pt mentation
0 = normal
4= coma

Question 4

Hepatic encephalopathy (HE) treatment

Answer 4

1. remove ppt factors for AMS (Benzos, opioids, antiseizure)
2. switch protein source to dairy/veg (BCAA>AAA)
3. Give lactulose to trap/dispel ammonia
4. Add on rifaximin if needed

Question 5

Acute HE treatment

Answer 5

Lactulose PO 25ml every hr until ≥2 watery stools
Poop the ammonia out

+/- Rifaximin 400mg PO Q8H

Question 6

Prevention of HE

Answer 6

Lactulose PO 15-60 mL Q6-12 hrs
Titrate to 2-3 soft bowel movements a day
+/- Rifaximin 550mg PO BID

Question 7

When to use Lactulose enema

Answer 7

Patient is in a coma or too altered to take meds orally/NG
or
Patient has tried PO therapy without any improvements