Hepatitis and Cirrhosis Flashcards
1
Q
LFTs?
A
Enzymes
- aminotransferases: ALT & AST
- AP
- GGT
synthetic fxn:
- serum albumin
- PT
Bili
2
Q
What are impt hx ?s to ask if you are concerned about liver disease?
A
- exposure to chemicals, meds, herbs
- accompanying sxs
- parenteral exposure
- IV and intranasal drug use
- tattoos and piercings
- sexual activity
- travel and exposure hx
- ETOH hx
3
Q
PE findings that suggest liver disease?
A
- cachexia: malnourishment (drinks a lot, drug user)
- stigmata of longstanding liver disease
- signs of alcoholic liver disease: acutely - large, if cirrhotic - small
- enlarged L supraclavicular node - HCC
- JVP suggests RHF secondary portal HTN
- R pleural effusion in absence of advanced ascited can be seen in cirrhosis (this can cause portal HTN)
4
Q
What is autoimmune hepatitis? Type 1 and type 2?
A
- chronic hepatitis: pp isn’t well understood
type 1 (classic): occurs in women of all age groups
type 2 (ALKM-1): occurs in girls and young women - characterized by circulating autoabs (not thought to be part of pp)
- high levels of serum globulin concentrations
5
Q
Clinical manifestations of autoimmune hepatitis?
A
- can be asx
- subclinical and those presenting with advanced cirrhosis
- fulminant hepatitis
- labs:
presence of serological markers
generally aminotransferases more elev than bili and AP
6
Q
Extrahepatic manifestations of autoimmune hepatitis?
A
- hemolytic anemia
- thyroiditis
- celiac sprue
- ITP
- DM I
- UC
(all of these are autoimmune)
7
Q
Tx of autoimmune hepatitis?
A
- corticosteroids for sx disease
risks/complications of steroids: - short term: HTN, high glucose, psychosis, insomnia, gastric irritation
- long term: osteoporosis, cataracts, PUD, immunosuppression
- azathioprine - 2nd line agent
8
Q
What is hemachromatosis?
A
- genetic disease due to autosomal recessive
- identified gene: HFE
- most common single gene disorder:
10% caucasians heterozygous
0.5% caucasians homozygous
very rare in other pops
9
Q
PP of hemochromatosis?
A
- gene defect results in increased iron absorption in the intestinal tract from the diet
- iron overload in the body
- eventual fibrosis and organ failure:
cirrhosis
cardiomyopathy
diabetes
hypogonadism
10
Q
Hematochromatosis - iron overload in the body? Why do females have delayed sxs?
A
- normal Fe: 3-4 mg/day
- normally Fe storage is controlled so there is no excess accumulation
- accum of 500-1000 mg/yr occurs in hemochromatosis
- sxs usually occur around age 40 or when Fe stores reach 15-40 g
- females have delayed sxs b/c of menstruation and breast feeding
11
Q
Clinical manifestations are influenced by what factors?
Classic presentation?
A
influenced by:
- age
- sex
- alcohol use
- dietary iron
- menstruation and breast feeding
- unkown factors
- alcohol abuse and hep C accelerate the process
- classic presentation: cutaneous hyperpigmentation w/ diabetes and cirrhosis
12
Q
Reversible manifestations of hemochromatosis?
A
- CV:
infections - cardiomyopathy (vibrio vulnificus)
conduction of disturbances
(monocytogenes)
- Liver: pastcuerlla pseudotubercullosis: abdominal pain, elevated LFTs, hepatosplenomegaly - skin: bronzing (melanin deposition) grayness (Fe deposition)
- listeria
13
Q
Irreversible manifestations of hemochromatosis?
A
- liver: cirrhosis, HCC
- anterior pituitary gland: gonadotropin insufficiency- hypogonadism
- pancreas: DM (30-60%)
- thyroid: hypothyroidism
- genitalia: primary hypogonadism
- jts: pseudogout
14
Q
Dx hemochromatosis?
A
- combo of:
clinical
lab: elevated serum transferrin sat of more than 45%, elevated serum ferritin (this is pathologic) - confirmation = gold std = liver bx (also defines extent of disease)
15
Q
Tx hemochromatosis?
A
- education for evidence of iron overload/complications: avoid red meat, Fe supps avoid ETOH avoid handling or eating raw seafood (increased risk of infections) receive vaccinations for Hep A and B - mainstay of tx: phlebotomy: removing 500 ml of blood removes 250 mg iron - do weekly until iron depletion: Hgb = 10-12 gm/dl ferritin less than 50 transferritin sat is less than 50% - maintenance: phlebotomy q 2-4 months
16
Q
Genetic testing for hemochromatosis?
A
- screen 1st degree relatives, unless under 18
- likely to uncover homozygotes who are asx
- screening test cost: $200, done on whole blood sample
17
Q
What is Wilson’s disease?
A
- hepatolenticular degeneration
- autosomal recessive
- affects copper metabolism
- organ damage due to copper build up in liver and brain
- easily tx if dx early
- difficult to dx
18
Q
Epidemiology and pathogenesis of Wilson’s disease?
A
- occurs worldwide: prevalence - 1/30,000 live births
- 1/90 persons carry the abnormal gene ATP7B
- pathogenesis:
gene affects the carrier protein of copper which is primarily in hepatocytes - it also impairs the excretion of copper via bile
19
Q
Clinical manifestations of Wilson’s?
A
- presentation varies widely and is often non-specific
- generally presents b/t 1st-3rd decade:
liver disease (usually presenting sx in young kids)
neuro sxs
psych sxs
20
Q
Dx and prognosis of Wilson’s
A
- dx:
ceruoplasmin level
24 hr urine for copper excretion
look for kayser fleischer rings in eyes - prognosis:
universally fatal if left untx
once dx chelation therapy with D-penicillamine is toc (lifelong)
21
Q
What are the 3 stages of alcoholic liver disease?
A
- fatty liver (steatosis)
- alcoholic hepatitis
- alcoholic fibrosis and cirrhosis
22
Q
Fatty liver - etiology, presentation, labs?
A
- most pts are asx
- can occur w/in hours of large alcohol binge and if continues to drink - it can progress
- may have tender hepatomegaly
- transaminases mildly elevated
- can also occur in obese individuals and pregnancy
23
Q
alcoholic hepatitis presentation?
A
- asx to extremely ill
- anorexia, N/V, wt loss, abdominal pain, poor nutritional status
- HSM
- jaundice
fever is common
24
Q
PE of alcoholic hepatitis?
A
- spider angiomas
- palmar erythema
- gynecomastia
- parotid enlargement
- testicular atrophy
- ascites
- encephalopathy
25
Lab findings in alcholic hepatitis?
- leukocytosis w/ left shift (in severe disease)
- anemia: most likely be macrocytic from B12 and folate deficiency, may have microcytic from GI blood loss
- transaminases elevated: AST:ALT ratio usually greater than 2:0 (ratio rarely seen in other forms of liver disease)
- increased AP (less than 3x the normal)
- hyperbilirubinemia (60-90%) - jaundice
- hypoalbunemia (severe disease)
- coagulopathy (severe)
- elevated ammnonia level (severe)
26
Complications of alcoholic LD?
- alcoholic fatty liver is reversible
- alcoholic hepatitis: is usually reversible, but may run a fulminant course progressing to fibrosis and death
- long standing alcoholic liver disease can lead to cirrhosis
- others:
GI bleeds
esophageal varices
gastritis/PUD
27
When do you see mallory bodies?
- when protein filaments are damaged in hepatocytes, appear pink on stain
- primarily seen with alcholic LD and wilsons
- will also see in HCC, even morbid obesity, assoc with severe liver disease
28
Tx of alcoholic LD?
- cessation of alcohol!!
- supportive tx:
nutrition
B12 and folate
fluids
R/O other causes for fever, liver disease such as Hep C, hemochromatosis, neoplasms
glucocorticosteroids for severe hepatitis
- liver transplant in approp pts
29
What are factors influencing toxicity in toxic hepatitis?
- excessive intake
- excessive cytoP450 activity
- decrease metabolism pathways in liver
- depletion of glutathione stores
- concomitant use of alcohol or other drugs
- comorbid illness
- advancing age
- nutritional status
30
Prevalence of drug-induce liver injury (DILI)?
- annual incidence w/ prescription meds 1/10,000
- DILI accounts for 10% of all adverse drug rxns
- ****DILI most common cause of liver failure in the US
- over 1000 meds and herbal products have been implicated in development of DILI
31
Level of injury of DILI?
- many drugs induce asx elevations in liver enzymes w/o causing disease
- DILI most common liver injury caused by drugs and accounts for 10% of all cases of acute hepatitis
- may be cholestasis, cytotoxic or mixed, less likely steatosis
- usually d/c of agent results in complete recovery
32
Most common drugs implicated in DILI in US?
- acetaminophen
| - abx
33
Tx for acetaminophen overdose?
- get an acetaminophen level
- activated charcoal if ingested w/in 2-3 hrs
- N-acetylcysteine for severe overdose
34
Signs and sxs of chronic acetaminophen intoxication? What pts are at the greatest risk for developing hepatotoxicity?
- signs and sxs are nonspecifc: confused w/ viral dx
- ask about acetaminophen usage, dosing
pts who are at greater risk for developing hepatotoxicity:
- ingestion of more than 7.5-10g over 24 hrs
- ingestion of less than 4 g with increased susceptibility
- liver tenderness, jaundice or ill-appearing
- supratherapeutic acetaminophen concentrations (over 20 mcg/mL)
35
Tx with NAC is recommended for which pts?
- all pts with liver tenderness and
- elevated aminotransferases and
- serum acetaminophen concentrations over 10 mcg/mL
- if serum acetaminophen concentrations are potentially toxic by the nomogram
36
General presentation of HAV, HBV, HCV, HEV?
- many cases can be asx especially in kids
- usually prodrome after exposure:
malaise and fatigue
anorexia, N/V
myalgias
pale stools, dark urine
jaundice
37
General signs of Hepatitis infection on exam?
- jaundice
- RUQ pain
- +/- hepatomegaly
38
Labs in Hepatitis infection?
- transaminases elevated, usually in 1000s with ALT more increased than AST
- hyperbilirubinemia
- bilirubinuria
- AP mildly elevated
- WBC normal to low
- may have prolonged PT
39
Acute viral hepatitis management?
- supportive care
- manage sxs
- no other liver toxins:
acetaminophen
alcohol
avoid exposure to other hepatitis viruses
- prevention: immunize HAV, HBV
40
What kind of virus is Hep A?
- RNA
41
Prevalence of HAV? Chronic infection?
- infection occurs worldwide
- incidence in US decreased substantially since vaccine initiated
- no chronic infection
42
HAV routes of transmission?
- fecal-oral route predominates
- close personal contact (household contact, sex contact, day car centers)
- contaminated food/water
- blood exposure
- maternal-fetal transmission hasn't been reported
43
What does a IgG antiHAV level tell you?
- the pt has either had HAV for 6 months or they have been vaccinated
44
What is the HAV vaccination?
- inactivated vaccine
- part of childhood vaccination series
- SE: fever, injection site rxns, rash, HA
- regimen: 2 doses 6-12 months apart
CDC recommendations:
- persons with clotting factor disorders or chronic liver dz
- MSM
- users of illegal drugs
- those traveling to countries with high or intermediate levels
- any person wishing to obtain immunity
45
Postexposure prophylaxis HAV?
- hep A vaccine or IG
- situations:
close personal contact
sexual contact
sharing IV drug apparatus
child care centers
schools, hospitals, other work settings
46
What type of virus is HBV?
- DNA, much more complicated than A
47
HBV epidemiology?
- est that there are more than 300 mill HBV carriers in the world
- US 125 mill infected
- over 350,000 deaths worldwide annually
- figures keep changing
48
HBV modes of transmission?
- sexual contact:
sexual spread major mode of transmission in developed countries:
heterosexual spread in US 39% new HBV infection
MSM 24% new HBV infections
- perinatal
major mode in underdeveloped countries
most infections occur at or near birth
- found in breast milk, but not a cause of transmission
```
- percutaneous:
IVDU
body piercing
nosocomial (Most commonly blood born infection in hosp setting)
- organ transplantation
- transfusions: very, very rare
```
49
HBV prevention?
- hepatitis vaccine
- post-exposure prophylaxis: give first dose of vaccine
administer HBIG at same time - diff site than vaccine
50
Clinical outcomes of acute HBV infections?
- 90% will resolve
- 9% will go on to have HBAg+ for greater than 6 mo - 50% of these will go on to resolve, the other 50% will either become asx carriers, chronic peristent hepatitis, or chronic active hepatitis - which can lead to cirrhosis, HCC, extrahepatic disease
- other 1% will go into fulminant hepatitis right a way
51
Signs and sxs of chronic HBV infection?
```
- many pts are asx
others:
-nonspecific sxs
-exacerbations similar to acute infection
-cirrhosis
- HCC
```
52
What are the extrahepatic manifestations of chronic Hep B?
```
- 10-20% due to circulating immune complexes:
fever
rash
arthralgias, arthritis
polyarteritis nodosa
glomerular disease
```
53
When does HbsAg appear? What does HbcAg indicate?
- HbsAg:
appears prior to onset of sxs
resolved infection becomes undetectable in 4-6 months
- persistence past 6 m = chronic infection
```
- HbcAg:
intracellular ag in affected hepatocytes, presence of Anti-HBc of IgM class indicates acute infection
```
54
When will you see anti-HBsAb?
- follows disappearance of HBsAg
- usually persists for life
- when coexists with HBsAg these persons are regarded as carriers of HBV
- presence of anti-HBs only, indicates immunity by vaccination
55
What is HbeAg a marker of?
- secretory protein
- marker of HBV replication and infectivity
- HBeAg to anti-HBe occurs early in pts with acute infection
- seroconversion is delayed for years in pts with chronic HBV, when they do seroconvert usually means remission of their disease
56
What are HBV DNA assays used for?
- used to assess HBV replication
- recovery from HBV assoc with disappearance of HBV DNA
- major role is in pts with chronic HBV to monitor for need for tx and response to tx
57
Tx for chronic HBV infection?
- interferon or peginterferon is agent of choice
- pts who show evidence of viral replication are candidates for therapy:
HBeAg + pts
high serum HBV DNA levels
active liver disease (chronic hepatitis on liver bx) or elevated LFTs
- pts who have decompensated cirrhosis or are carriers shouldn't receive txs
58
SEs of peginterferon?
- flu-like sxs
- immunosuppression
- abdominal pain, N/V, dry mouth
- hair loss
- blurred vision
- depression
- anemia
- going to be on this for 9 months
59
Other meds for tx Hep B?
- 1. Hep B easily becomes resistant so often a combo has been used
- 2. tx is for months
- 3. meds are complicated and have multiple side effects so refer to specialist
```
- meds:
lamivudine (epivir)
adefovir (hepsera)
entecavir (baraclude)
telbivudine (tyzeka)
```
60
```
A pt presents with these lab serologies:
HBeAg +
HBsAg +
IgM anti-HBc +
what does this pt have?
```
acute HBV infection
61
A pt presents with following lab results:
HBsAg + (greater than 6 mo)
HBV DNA +
ALT and AST moderately elevated ALT more than AST
- what does this pt have?
-chronic HBV infection
62
HCV epidemiology?
- fallen from 230,000/year in 80s to current level 19,000 cases in 2006
- one of the most common chronic liver diseases
- majority of liver transplants in US are for chronic HCV
63
Transmission of HCV?
- highest rate: IVDU/having sex with IVDU
- having been in jail for more than 3 days
- religious scarification
- blood transfusion - since routine testing risk very low
- having been struck or cut with blood object
- pierced ears or body parts
- immunoglobulin injection
- perinatal transmission can occur
- solid organ transplant
64
Who should be screened for HCV?
- ever injected illegal drugs
- received clotting factors made b/f '87
- received blood/organs b/f july 1992
- were ever on chronic hemodialyis
- have evidence of liver disease (increased ALT)
- are infected with HIV
- healthcare workers after needle stick/mucosal exposure to HCV + blood
- children born to HCV + mothers
65
Natural hx of HCV?
- 20% will recover
- 80% will go on to have a persistent infection, of this %, 30% will have stable chronic hepatitis, 40% will have variable progression, and 30% will have severe progression
66
Chronic HCV infection presentation?
- 80-100% pts remain HCV RNA positive
- 60-80% have persistently elevated liver enzymes
- sxs:
most common complaint is fatigue, sxs are rarely incapacitating, but may lead to a decrease in quality of life
- HCV accounts for 1/3 of HCC cases in US
67
Dx HCV?
- HCV RNA rises within 8 days to 8 wks following exposure
- anti-HCA is + within 12 weeks after exposure
- sometimes difficult to distinguish acute from chronic as both HCV RNA and anti-HCV are present in both
- chronic infection - have it for 6 or more months
68
Management of chronic HCV?
- assess for severity of disease
- tx as indicated
- counsel to reduce further harm to liver - no drinking, drugs
- if not already done vaccinate against A and B
69
PT selection for therapy for chronic HCV?
- selection criteria where therapy is widely accepted
- some criteria where therapy is considered
- pt criteria where therapy is CI
- pt eval for therapy:
liver bx - almost all pts undergo this
test for HIV
eval for other types of liver disease
continued IVDU or alcohol abuse
70
Tx for chronic HCV infection?
- combo of antivirals:
peginterferon
ribavarin
protease inhibitors
- assessing tx response:
HCV RNA negativity
sustained response HCV RNA negativity 6 months after tx is stopped
71
SEs of peg interferon/ribavirin?
- bone marrow suppression
- myalgias, HAs, low grade fevers - common 1st 48hrs after infusion
- neuropsych sxs (irritability) - must screen for depression
- non-productive cough and dyspnea
- ocular: ischemic retinopathy, retinal hemorrhage - eval by ophtho
- thyroid dysfxn: monitor
- rash, hair loss, hearing loss, insomnia
72
What protease inhibitor shows promise for tx HCV? Downside?
- Harvoni - tablet of 2 protease inhibitors that are showing promise but super expensive
- many side effects: including death!
73
Liver transplant process in HCV pts?
- non-infected liver transplanted into HCV infected pt becomes infected and decreases survival
- tx with peginterferon + ribavirin may prolong survival
- using a younger liver or a liver that is already HCV infected seems to help
74
Why is HDV unique? RNA or DNA?
- requires HBV for replication (must have HBV first)
- HBsAg coat
- single stranded RNA rod-like structure
- HDV:
small HDAg activates replication of HDV RNA in hepatocyte
large HDAg directs packaging HD virion into HBsAg
lipoprotein envelope is provided by HBV
75
Genotypes of HDV?
- genotype 1:
western world
increased risk of fulminant course when compared to acute HBV, progression towards cirrhosis is rapid
- genotype 2: far East
- genotype 3: Venezuela, Columbia, Brazil, Peruvian and Amazon bases
- 5 other genotypes known
76
Transmission of HDV?
- parenteral
- close personal contact
- multiple transfusions
- contaminated dialysis equipment
10% HBV pts have HDV
HDV may be cytotoxic
77
Coinfections: HBV and HDV?
- coinefction w/ HBV: severe acute disease B+D, usually self limited (direct cytopathic damage)
low risk of chronic infection
- superinfection on top of chronic HBV:
usually develop chronic HDV infection, HBV suppressed
high risk of severe, progressive chronic liver disease (immune damage)
78
HDV prevention and tx?
- HBV vaccination
- HBV-HDV coinfection:
pre- or post-exposure prophylaxis to prevent HBV infection (immunoglobulin and vaccine)
- chronic HDV tx with peginterferon
79
What kind of virus is HEV? How is it transmitted? Is there a chronic form?
- RNA
- enterically transmitted, waterborne virus, spread by fecally contaminated water, person to person transmission is rare
- can be transmitted via blood transfusion in endemic areas
- can be transmitted from mother to newborn
- US cases usually have travel hx to HEV endemic area
- no chronic form
80
What is HGV?
- - GB virus type C (GBV-C)
- HGV was initially cloned from a surgeon
- 2 diff agents isolatedL A, B, C - C is identical to HGV
- high incidence in US
- flavivirus - can be spread through contaminated blood and sxual contact
- evidence suggests that it doesn't cause hepatitis in humans
- protective effect on pts coinfected w/ HIV
81
What are complications of acute hepatitis?
- cholestatic hepatitis
- raging fulminant hepatitis
- chronic hepatitis
82
How do you dx chronic hepatitis?
| Typical progression?
- disease staging b/f tx
- f/u after tx
- typical progression:
chronic inflammation in portal areas
necrosis/inflammation (moderate activity)
fibrosis (marked activity)
cirrhossi (non-reversible)
83
What hepatitis viruses can cause chronic hepatitis?
fulminant?
- B, C, D
| - fulminant: all except G
84
What is cirrhosis?
- development of fibrosis of liver with formation of regenerative nodules; results in impairment of synthetic, metabolic, and hemodynamic fxns of the liver
85
How do you dx cirrhosis?
- imaging studies: US, CT, MRI can SUGGEST dx
- Bx is GOLD std
- determine underlying etiology using Hx and labs:
chronic hepatitis
alcoholic hepatitis
wilson's disease
86
Etiologies of cirrhosis?
- alcohol and chronic HCV in US account for 1/2 of transplant pts
- 10-15% are cryptogenic (dx of exclusion)
- primary biliary cirrhosis (PBC)
- chronic HBV
- wilson's disease
- hemochromatosis
- nonalcoholic steatohepatitis
87
PP of cirrhosis?
- process of scarring of the liver
- normally the extracellular matrix has diff types of collagen and glycoproteins that are in balance
- as chronic insult to the liver persists over years the collagen production in the liver increases 4-10 fold
- the ECM becomes stiffer and normal fxns of the liver are compromised
- the change in the ECM affects hepatic stellate cells
- early fibrotic changes are reversible, as progression occurs the change becomes irreversible
88
Lab abnormalities in cirrhosis?
- aminotransferases: AST/ALT: moderately elevated
- AP: elevated but less than 2-3x normal, higher elevations suspect primary sclerosing cholangitis or PBS
- bilirubin: level rise as cirrhosis progresses
- albumin: levels fall as cirrhosis worsens
- PT: increases as ability of cirrhotic liver to synthesize clotting factors diminishes
- serum Na: hyponatremia seen with ascites
high levels of ADH - because of portal HTN - taking protein into abdomen, and fluid is following, less amt of fluid in vasculature - so secrete more ADH to hold onto more fluid
89
more lab abnormalities in cirrhosis - hematologic?
- thrombocytopenia: usually first, secondary to HTN and attendant congestive splenomegaly
- leukopenia: hypersplenism with margination
- anemia:
acute/chronic GI blood loss
folate deficiency (occurs early in malnutrition, B12 def occurs much later)
bone marrow suppression
anemia of chronic disease (Inflammation)
90
Why will there likely be portal HTN in cirrhosis?
- increased BP in portal vein due to increased resistance to blood passing through vessels in liver
- results in:
alt routes:
esophageal varices
enlarged abdominal wall vessels (caput medusa), hemorrhoids
splenomegaly
ascites (protein rich fluid)
91
How can we manage portal HTN?
- temp measures: remove ascitic fluid
- portal shunts
- tx liver disease
- liver transplant
92
What can hepatic encephalopathy lead to?
- potentially reversible neuropsych abnormalities:
cognitive abilities
psychiatric state
motor impairment, including focal near findings
- syndrome observed in pts with cirrhosis:
prereq is a diversion of portal blood to systemic circulation, can occur in pts w/o cirrhosis who have surgically created portosystemic shunts
93
What other precipitating causes of HE need to be ruled out before you blame it cirrhosis?
- hypovolemia
- GI bleed
- hypokalemia/metabolic alkalosis
- hypoxia
- sedatives or tranquilizers
- hypoglycemia
- infection (SBP)
- rarely hepatoma or vascular occlusion
94
How do you grade the severity of HE?
- west-haven classifciation system:
0-4
- glasgow coma scale may be used in severe HE
95
How do you dx HE?
- ammonia and manganese are neurotoxins that precipitates HE
- serial ammonia levels are inferior to clinical assessment in gauging improvement or deterioration in pt who is being tx for HE
- EEG findings are not specific to HE, but if seizure activity needs to be ruled out an EEG may be helpful
- CT and MRI are helpful in ruling intracranial lesions
96
How do you tx HE?
- determin stage of HE
- exclude nonhepatic casues of alt mental fxn
- need to lower ammonia levels: for overt HE use
lactulose -
give enough so that the pt has 3-4 soft stools a day
SE: abdominal cramping, bloating, flatulence, enemas, electrolyte abnormalities
- severe SEsL ileus and hypovolemia to pt of worsening HE
- correct hypokalemia if present
- low protein diet may be helpful
-rifampin orally effects the metabolic fxn of the gut microbiota and is effective as laculose but with less SEs
- for more severe HE the pt may be at risk of aspiration and may need to be intubated
97
DDx of HE?
- intracranial lesions
- infections
- metabolic encephalopathy
- toxic encephalopathy
- organic brain syndrome
- postseizure encephalopathy
