HEPATIC ENCEPHALOPATHY Flashcards
Hepatic encephalopathy develops as a result of the inability of the liver to detoxify……………..
Ammonia and other chemicals
Conditions that cause hepatic encephalopathy
Viral hepatitis
Alcoholic hepatitis
Cirrhosis
Hepatocellular carcinoma
Drugs
Fatty liver of pregnancy
Drugs that can cause hepatic encephalopathy
Paracetamol overdose
Isoniazid
Halothane
Herbal preparations
Precipitating factors of hepatic encephalopathy in a
patient with pre-existing liver disease
Fever
Hypotension
Infection
Fluid and electrolyte imbalance
Sedatives
Increased GIT protein load
Factors that can cause increased GIT protein load
Heavy GIT bleeding
Alcoholic binge
Symptoms of hepatic encephalopathy include
Jaundice
Confusion
Disturbed consciousness
Personality changes
Signs of hepatic encephalopathy
Cyanosis
Fetor hepaticus
Signs of chronic liver disease
Neurological abnormalities
In hepatic encephalopathy, disturbed consciousness which progresses as follows
Disorder of sleep, hypersomnia and inversion of sleep rhythm, apathy and
eventually coma
Neurological abnormalities in hepatic encephalopathy
Speech impairment
Asterixis
Inability to draw or construct objects e.g. a 5-pointed star
Incoordination
Lethargy
Encephalopathy
Grading of hepatic encephalopathy
Grade 1: Mild confusion, irritable, tremor, restless
Grade 2: Lethargic responses, decreased inhibitions, disorientation, agitation, asterixis
Grade 3: Stuporous but arousable, aggressive bursts, inarticulate speech and marked confusion
Grade 4: Coma
……… indicates pre-coma and strongly supports the diagnosis of encephalopathy
Asterixis (a flapping tremor)
Investigations in hepatic encephalopathy
FBC
Blood glucose
Liver function tests
Blood urea and electrolytes
Hepatitis B-surface-Antigen
Hepatitis C screen
Prothrombin time, INR
Infection screen
Components of an infection screen in hepatic encephalopathy
Blood culture
Urine RE
Chest X-Ray
Diagnostic ascitic tap
Treatment objectives in hepatic encephalopathy
To identify and correct precipitating factors promptly
To treat underlying cause of liver disease
Non-pharmacological management of hepatic encephalopathy
Place in the coma position if unconscious
Maintain fluid and electrolyte balance
Monitor vitals
Avoid alcohol, paracetamol and other hepatotoxic agents
Avoid sedatives such as benzodiazepines and drugs that impair the coagulation system
Patients should NOT have their protein intake restricted
Encourage intake of high carbohydrate diet by mouth or NG tube
Maintain an adequate protein intake of ……………. in hepatic encephalopathy
1.2-1.5 g/kg per day
Measures to correct hydration status and nutrition in hepatic encephalopathy in adults
Dextrose saline (5-10% dextrose in 0.9% saline), IV, 500 ml 8 hourly
(according to requirements)
And
High potency Vitamin B, IV, (formulated as two separate vials) One pair of vials daily (added to glucose IV solution)
Measures to correct hydration status and nutrition in hepatic encephalopathy in children
Dextrose saline (4.3% in 0.18% saline), IV,
And
High potency Vitamin B, IV, (formulated as two separate vials)
Measures to lover blood ammonia concentration in hepatic encephalopathy
Lactulose oral or rectal
and
Metronidazole or Rifaximin
Dose of oral lactulose in hepatic encephalopathy
Adults
Start with 30-45 ml (20-30 g), 6-12 hourly
(Review dose to maintain 2-3 semi-solid stools per day)
Children and Adolescents
Start with 5-20 ml 6-12 hourly
(Review dose to maintain 2-3 semi-solid stools per day)
Neonates
Start with 0.5-5 ml 6-12 hourly
(Review dose to maintain 2-3 semi-solid stools per day)
Dose of rectal lactulose in hepatic encephalopathy
Lactulose, rectal,
300 ml diluted in 700 ml water (via rectal balloon catheter) 4-6 hourly, retain in the rectum for 30-60 minutes.
(Review dose to maintain 2-3 semi-solid stools per day)
Dose of metronidazole in hepatic encephalopathy
Metronidazole, oral,
Adults
400 mg 8 hourly
Children
15 mg/kg 12 hourly
Neonates
> 2 kg; 15 mg/kg 12 hourly
1-2 kg; 7.5 mg/kg 12 hourly
Dose of rifaximin in hepatic encephalopathy
Rifaximin, oral,
Adults
550 mg 12 hourly
Children
> 12 years; 200 mg 8 hourly
< 12 years; not recommended
Management of bleeding in hepatic encephalopathy associated with active bleeding (INR > 1.5
or platelet count < 50 x 109 /L)
Adults and Children
Fresh frozen plasma, IV, (for INR>1.5)
Or
Platelet concentrate, IV, (platelet count < 50 x 10^9 /L)
Antibiotic prophylaxis in Hepatic encephalopathy (associated with
cirrhosis and upper gastro-intestinal haemorrhage)
Ciprofloxacin, IV,
Adults
400 mg 8-12 hourly (administered over 60 minutes)
Or
Ceftriaxone, IV, 1 g daily for 7 days
Or
Ciprofloxacin, oral, 500 mg 12 hourly
Or
Norfloxacin, oral, 400 mg 12 hourly for 7 days
First line treatment of hepatic encephalopathy precipitated by bacterial infection
Ciprofloxacin, IV, 400 mg 8-12 hourly for 2 days (to be administered over 60 minutes)
Then
Ciprofloxacin, oral, 500 mg 12 hourly for 5 days
Second line treatment of hepatic encephalopathy precipitated by bacterial infection
Cefotaxime, IV, 2 g 8 hourly for 7 days
Or
Ceftriaxone, IV, 2 g daily for 7 days
Diagnosis of SBP
A diagnosis of SBP is established if the neutrophil count in the ascitic fluid is > 250 cells/mL, culture results positive and surgically treatable causes are excluded
