View source for Hepatic encephalopathy

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==Background==

*Diagnosis of exclusion
*Due to accumulation of nitrogenous waste products normally metabolized by the liver
*Increased metabolism of ammonia to glutamine in CNS
*Spectrum of illness ranges from chronic fatigue to acute lethargy


===Precipitants===

*Increased ammonia production, absorption or entry into brain:
**[[Special:MyLanguage/GI Bleed|GI Bleed]]
**Excess dietary intake of protein
**[[Special:MyLanguage/Infection|Infection]] (e.g. [[Special:MyLanguage/SBP|SBP]])
**[[Special:MyLanguage/Hypokalemia|Hypokalemia]]
**[[Special:MyLanguage/Metabolic Alkalosis|Metabolic Alkalosis]]
**[[Special:MyLanguage/Constipation|Constipation]]
*[[Special:MyLanguage/Dehydration|Dehydration]]
**[[Special:MyLanguage/Vomiting|Vomiting]]
**[[Special:MyLanguage/Diuretics|Diuretics]]
*Drugs
**[[Special:MyLanguage/Opioids|Opioids]] 
**[[Special:MyLanguage/Benzodiazepines|Benzodiazepines]] (including [[Special:MyLanguage/benzodiazepine withdrawal|withdrawal]])
**[[Special:MyLanguage/ETOH|ETOH]] (including withdrawal)


==Clinical Features==

[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:Hepaticfailure.jpg|thumb||Ascites secondary to [[Special:MyLanguage/cirrhosis|cirrhosis]].]]

===Stages===

*Stage I - General apathy
*Stage II - Lethargy, drowsiness, variable orientation, asterixis
*Stage III - Stupor with hyperreflexia, marked disorientation, inability to follow commands, extensor plantar reflexes
*Stage IV - Coma


==Differential Diagnosis==

*[[Special:MyLanguage/Subdural Hematoma|Subdural Hematoma]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*[[Special:MyLanguage/Wernicke-Korsakoff Syndrome|Wernicke-Korsakoff Syndrome]]
*[[Special:MyLanguage/hypernatremia|Hyper]]/[[Special:MyLanguage/hyponatremia|hyponatremia]]
*[[Special:MyLanguage/Benzodiazepine Overdose|Benzodiazepine Overdose]] (decreased hepatic clearance)
*[[Special:MyLanguage/Renal Failure|Renal Failure]]
*[[Special:MyLanguage/Sepsis|Sepsis]]


==Evaluation==


===Workup===

*CBC
*Chemistry
*Ammonia level
*[[Special:MyLanguage/LFTs|LFTs]]
*PT/PTT
*[[Special:MyLanguage/Urinalysis|Urinalysis]]
*[[Special:MyLanguage/CXR|CXR]]
*[[Special:MyLanguage/Head CT|Head CT]]
*[[Special:MyLanguage/Paracentesis|Paracentesis]] in patient with ascites (rule out [[Special:MyLanguage/SBP|SBP]])
*Consider [[Special:MyLanguage/LP|LP]]


===Evaluation===

*Full neuro exam including asterixis
*[[Special:MyLanguage/Elevated ammonia|Elevated ammonia]] level. Ammonia is not predictive of severity of disease.
*History of any new medications or toxin ingestion
*Focus exam on looking for signs of [[Special:MyLanguage/GI bleed|GI bleed]] or [[Special:MyLanguage/hypovolemia|hypovolemia]]


==Management==

*[[Special:MyLanguage/Lactulose|Lactulose]] 20g PO or (300mL in 700cc H2O retention enema x30min)
**In colon degrades into lactic acid: acidic environment traps ammonia
**Also inhibits ammonia production in gut wall

*Rifaximin is second line.
*Some new evidence suggest use of PEG in patients who are not candidates for Lactulose.



==Medication Dosing==
{{MedicationDose
| drug = Lactulose
| dose = 20g PO or 300mL in 700mL H2O retention enema x 30min
| route = PO or rectal
| context = First-line treatment for hepatic encephalopathy
| indication = Hepatic encephalopathy
| population = Adult
}}

==Disposition==

*Discharge stage I if good resources.
*Stage II will need admission unless known encephalopathy and who is otherwise well.
*Stage III and IV admission +/- ICU or obs bed.


==Patient Information==

[http://www.nlm.nih.gov/medlineplus/ency/article/000302.htm Hepatic Encephalopathy] (Medline Plus)


==See Also==

*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]


==References==

<references/>
[[Category:GI]]
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