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Hepatic Encephalopathy

Hepatic Encephalopathy. UMASS ECHO Curtis Barry, MD March 31, 2017. HEPATIC ENCEPHALOPATHY. Hepatic Encephalopathy. Definitions. Hepatic Encephalopathy Potentially reversible neuropsychiatic abnormalities seen in patients with liver dysfunction or porto -systemic shunting

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Hepatic Encephalopathy

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  1. Hepatic Encephalopathy UMASS ECHO Curtis Barry, MD March 31, 2017

  2. HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy

  3. Definitions • Hepatic Encephalopathy • Potentially reversible neuropsychiatic abnormalities seen in patients with liver dysfunction or porto-systemic shunting • Minimal Hepatic Encephalopathy • Subclinical encephalopathy in patients with liver dysfunction, only detectable with specialized neuropsychiatric tests

  4. Epidemiology • 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

  5. PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy Pathogenesis Toxins NH3 Shunting Failure to metabolize NH3 GABA-BD receptors Bacterial action Protein load

  6. STAGES OF HEPATIC ENCEPHALOPATHY Stages of Hepatic Encephalopathy Stage 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

  7. HEPATIC ENCEPHALOPATHY IS A CLINICAL DIAGNOSIS Hepatic 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

  8. Stroop App

  9. Hepatic Encephalopathy Precipitants Sedatives / hypnotics Excess protein GI bleeding TIPS Diuretics Serum K+ Plasma volume Azotemia Temp Infections

  10. TREATMENT OF HEPATIC ENCEPHALOPATHY Treatment of Hepatic Encephalopathy • Identify and treat precipitating factor • Infection • GI hemorrhage • Prerenal azotemia • Sedatives • Constipation • Lactulose (adjust to 2-5 bowel movements/day) • RIFAXIMIN

  11. ACTIONS OF LACTULOSE Actions of Lactulose NH3 Decreased pH NH4+ Lactic acid NH3 Lactulose Urease-producing bacteria Increase cathartic effect

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