Curtis Barry MD March 31 2017 HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy Definitions Hepatic Encephalopathy Potentially reversible neuropsychiatic abnormalities seen in patients with liver dysfunction or ID: 917126
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Slide1
Hepatic Encephalopathy
UMASS ECHO
Curtis Barry, MD
March 31, 2017
Slide2HEPATIC ENCEPHALOPATHY
Hepatic Encephalopathy
Slide3Definitions
Hepatic Encephalopathy
Potentially reversible
neuropsychiatic abnormalities seen in patients with liver dysfunction or porto-systemic shuntingMinimal Hepatic EncephalopathySubclinical encephalopathy in patients with liver dysfunction, only detectable with specialized neuropsychiatric tests
Slide4Epidemiology
30-45% of patients with decompensated cirrhosis have HE
20% annual risk of development in patients with compensated cirrhosis
60-80% of patients with compensated cirrhosis have evidence of minimal HE
Slide5Slide6Slide7Hepatic Encephalopathy Pathogenesis
Bacterial action
Protein load
Failure to metabolize NH
3
NH
3
Shunting
GABA-BD
receptors
Toxins
PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY
Slide8Stage Mental state Neurologic signs
1 Mild confusion: limited attention Incoordination, tremor,
span, irritability, inverted sleep impaired handwriting
pattern
2 Drowsiness, personality changes, Asterixis, ataxia, dysarthria
intermittent disorientation
3 Somnolent, gross disorientation, Hyperreflexia, muscle
marked confusion, slurred speech rigidity, Babinski sign
4 Coma No response to pain,
decerebrate posture
Stages of Hepatic Encephalopathy
STAGES OF HEPATIC ENCEPHALOPATHY
Slide9Hepatic Encephalopathy Is A Clinical Diagnosis
Clinical findings and history important
Ammonia levels are unreliable
Ammonia has poor correlation with diagnosis
Measurement of ammonia
not
necessary
Number connection test
Slow dominant rhythm on EEG
HEPATIC ENCEPHALOPATHY IS A CLINICAL DIAGNOSIS
Slide10Stroop App
Slide11Slide12Hepatic Encephalopathy Precipitants
GI bleeding
Excess protein
Sedatives / hypnotics
TIPS
Diuretics
Serum K
+
Plasma volume
Azotemia
Temp
Infections
Slide13Slide14Treatment of Hepatic Encephalopathy
Identify and treat precipitating factor
Infection
GI hemorrhage
Prerenal azotemia
Sedatives
Constipation
Lactulose (adjust to 2-5 bowel movements/day)
RIFAXIMIN
TREATMENT OF HEPATIC ENCEPHALOPATHY
Slide15Actions of Lactulose
Lactulose
Lactic acid
Decreased pH
NH
3
Urease-producing bacteria
Increase cathartic effect
NH
3
NH
4
+
ACTIONS OF LACTULOSE
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