Hepatic encephalopathy: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Workup=== | |||
*CBC | |||
*Chemistry | |||
*Ammonia level | *Ammonia level | ||
*LFTs | |||
*PT/PTT | |||
*UA | |||
*CXR | |||
*Head CT | |||
*Paracentesis in patient with ascites (rule out [[SBP]]) | |||
*Consider [[LP]] | |||
===Evaluation=== | |||
*Elevated ammonia level | |||
*History of any new medications or toxin ingestion | *History of any new medications or toxin ingestion | ||
*Focus exam on looking for signs of GI bleed or hypovolemia | *Focus exam on looking for signs of GI bleed or hypovolemia | ||
==Treatment== | ==Treatment== | ||
Revision as of 12:40, 26 August 2015
Background
- Diagnosis of exclusion
- Due to accumulation of nitrogenous waste products normally metabolized by the liver
- Spectrum of illness ranges from chronic fatigue to acute lethargy
Precipitants
- Increased ammonia production, absorption or entry into brain:
- GI Bleed
- Excess dietary intake of protein
- Infection
- Hypokalemia
- Metabolic Alkalosis
- Constipation
- Dehydration
- Vomiting
- Diuretics
- Drugs
- Opioids
- Benzodiazepines (including withdrawal)
- ETOH (including withdrawal)
Clinical Features
Stages
- Stage I - General apathy
- Stage II - Lethargy, drowsiness, variable orientation, asterixis
- Stage III - Stupor with hyperreflexia, extensor plantar reflexes
- Stage IV - Coma
Differential Diagnosis
- Subdural Hematoma
- Hypoglycemia
- Wernicke-Korsakoff Syndrome
- Hyper/hyponatremia
- Benzodiazepine Overdose (decreased hepatic clearance)
- Renal Failure
- Sepsis
Diagnosis
Workup
- CBC
- Chemistry
- Ammonia level
- LFTs
- PT/PTT
- UA
- CXR
- Head CT
- Paracentesis in patient with ascites (rule out SBP)
- Consider LP
Evaluation
- Elevated ammonia level
- History of any new medications or toxin ingestion
- Focus exam on looking for signs of GI bleed or hypovolemia
Treatment
- Lactulose 20mg 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
Disposition
- Discharge stage I or II with known ecephalopathy and who is otherwise well
Patient Information
Hepatic Encephalopathy (Medline Plus)