HEPATIC ENCEPHALOPATHY

Question 1

Hepatic encephalopathy develops as a result of the inability of the liver to detoxify……………..

Answer 1

Ammonia and other chemicals

Question 2

Conditions that cause hepatic encephalopathy

Answer 2

Viral hepatitis
Alcoholic hepatitis
Cirrhosis
Hepatocellular carcinoma
Drugs
Fatty liver of pregnancy

Question 3

Drugs that can cause hepatic encephalopathy

Answer 3

Paracetamol overdose
Isoniazid
Halothane
Herbal preparations

Question 4

Precipitating factors of hepatic encephalopathy in a
patient with pre-existing liver disease

Answer 4

Fever
Hypotension
Infection
Fluid and electrolyte imbalance
Sedatives
Increased GIT protein load

Question 5

Factors that can cause increased GIT protein load

Answer 5

Heavy GIT bleeding
Alcoholic binge

Question 6

Symptoms of hepatic encephalopathy include

Answer 6

Jaundice
Confusion
Disturbed consciousness
Personality changes

Question 7

Signs of hepatic encephalopathy

Answer 7

Cyanosis
Fetor hepaticus
Signs of chronic liver disease
Neurological abnormalities

Question 7

In hepatic encephalopathy, disturbed consciousness which progresses as follows

Answer 7

Disorder of sleep, hypersomnia and inversion of sleep rhythm, apathy and
eventually coma

Question 8

Neurological abnormalities in hepatic encephalopathy

Answer 8

Speech impairment
Asterixis
Inability to draw or construct objects e.g. a 5-pointed star
Incoordination
Lethargy
Encephalopathy

Question 9

Grading of hepatic encephalopathy

Answer 9

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

Question 10

……… indicates pre-coma and strongly supports the diagnosis of encephalopathy

Answer 10

Asterixis (a flapping tremor)

Question 11

Investigations in hepatic encephalopathy

Answer 11

FBC
Blood glucose
Liver function tests
Blood urea and electrolytes
Hepatitis B-surface-Antigen
Hepatitis C screen
Prothrombin time, INR
Infection screen

Question 12

Components of an infection screen in hepatic encephalopathy

Answer 12

Blood culture
Urine RE
Chest X-Ray
Diagnostic ascitic tap

Question 13

Treatment objectives in hepatic encephalopathy

Answer 13

To identify and correct precipitating factors promptly
To treat underlying cause of liver disease

Question 14

Non-pharmacological management of hepatic encephalopathy

Answer 14

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

Question 15

Maintain an adequate protein intake of ……………. in hepatic encephalopathy

Answer 15

1.2-1.5 g/kg per day

Question 16

Measures to correct hydration status and nutrition in hepatic encephalopathy in adults

Answer 16

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)

Question 17

Measures to correct hydration status and nutrition in hepatic encephalopathy in children

Answer 17

Dextrose saline (4.3% in 0.18% saline), IV,
And
High potency Vitamin B, IV, (formulated as two separate vials)

Question 18

Measures to lover blood ammonia concentration in hepatic encephalopathy

Answer 18

Lactulose oral or rectal
and
Metronidazole or Rifaximin

Question 19

Dose of oral lactulose in hepatic encephalopathy

Answer 19

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)

Question 20

Dose of rectal lactulose in hepatic encephalopathy

Answer 20

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)

Question 21

Dose of metronidazole in hepatic encephalopathy

Answer 21

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

Question 22

Dose of rifaximin in hepatic encephalopathy

Answer 22

Rifaximin, oral,
Adults
550 mg 12 hourly

Children
> 12 years; 200 mg 8 hourly
< 12 years; not recommended

Question 23

Management of bleeding in hepatic encephalopathy associated with active bleeding (INR > 1.5
or platelet count < 50 x 109 /L)

Answer 23

Adults and Children
Fresh frozen plasma, IV, (for INR>1.5)
Or
Platelet concentrate, IV, (platelet count < 50 x 10^9 /L)

Question 24

Antibiotic prophylaxis in Hepatic encephalopathy (associated with
cirrhosis and upper gastro-intestinal haemorrhage)

Answer 24

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

Question 25

First line treatment of hepatic encephalopathy precipitated by bacterial infection

Answer 25

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

Question 26

Second line treatment of hepatic encephalopathy precipitated by bacterial infection

Answer 26

Cefotaxime, IV, 2 g 8 hourly for 7 days
Or
Ceftriaxone, IV, 2 g daily for 7 days

Question 27

Diagnosis of SBP

Answer 27

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