diagnosis Hepatic encephalopathy
1- Acute or chronic disease of liver cells or protosystemic shunts
2- Consciousness and thinking disorders that may range from forgetfulness and confusion to stupor and coma
3- Neurological symptoms including asterixia, hyperreflexia, positive Babinski, rigidity and rarely seizures
4- Characteristic encephalogram with high voltage and slower aphasic wave
Hepatic encephalopathy It is divided into two types:
1- Acute hepatic encephalopathy:
– Occurs in the context of liver fulminan failure. (acute viral hepatitis, fatty liver of pregnancy, use of hepatotoxins such as acetaminophen, isoniazid, halothane, valproic acid, and fungal toxins)
Cerebral edema plays an important role in this type of encephalopathy
– Coma is common
– It has a very high mortality rate
2- Chronic hepatic encephalopathy:
– It occurs in the context of cirrhosis and is often reversible
– It manifests itself in the form of disturbances in the sleep-wake cycle, behavioral disorders, and neurological dysfunction
Pathogenesis Hepatic encephalopathy In the context of cirrhosis, it mostly requires insufficient liver removal of nitrate compounds or other poisons eaten or formed in the digestive system. Ammonia derived from amino acid deamination and bacterial hydrolysis of nitrogenous compounds in the intestine indicates pathogenesis. Hepatic encephalopathy has it.
Predisposing factors of hepatic encephalopathy include:
1- Increasing the nitrogen load
– digestive bleeding
– Increase in dietary protein
2- Electrolytic and metabolic imbalance
– Sleeping pills (sedatives) such as benzodiazepines – TCAs
4- Other materials included
– Progressive liver disease
– What are port shunts?
Clinical manifestations of hepatic encephalopathy include:
1- Disorder in brain function (impairment in comprehension and understanding – personality disorder – dementia – apraxia and impaired consciousness)
2- Neuromuscular dysfunction with symptoms such as asterixis, hyperreflexia, myoclonus
3- Rarely, a syndrome similar to Parkinson’s and progressive paraplegia
Patients usually show symptoms of chronic liver failure, which in the examination and tests are related to liver dysfunction, and the symptoms include: muscle wasting, jaundice, ascites, palmar erythema, edema and spider telangiectasia.
– It is one of the earliest manifestations of sleep-wake cycle disorder
Differential diagnoses: (DDX)
3- Subdural hematoma
4- Excessive use of sedatives
5- Acute alcohol poisoning
Laboratory tests: (LAB tests)
Liver functional and biochemical tests are often disturbed, and water and electrolyte disorders such as hyponatremia and hypokalemia are seen, which is the result of portal hypertension and the use of diuretics.
Ammonium is the best diagnostic neurotoxin that causes hepatic encephalopathy.
But other tests can rule out other causes unrelated to the liver, including hypocalcemia, uremia, electrolyte disorders, and intoxication.
Several specific tests for diagnosis Hepatic encephalopathy It exists, but in the hospital, the diagnosis is based on clinical and laboratory findings and the rejection of other causes of change in the level of consciousness.
After the diagnosis of the disease, the stage of the disease is helpful, which is based on the change in the level of consciousness, intelligent function and basic behavior, but does not include asterixis and neurological symptoms.
Stages of encephalopathy
Reversal of sleep patterns
– Slowing down of intellectual activities
– Calculation disorder – Writing disorder
– Decreased consciousness
– Increased reflexes
– Positive Babinski
– Coma (only response to painful stimuli)
In patients with cirrhosis, in most cases, even seemingly healthy patients have some degree of measurable disorders of intelligent function, long-term memory, and learning ability.
The goal of treatment is to remove predisposing factors and reduce ammonia and other blood toxins.
– If necessary, oxygen therapy, mechanical ventilation and dextrose infusion
– Patients with hepatic encephalopathy are usually agitated, in which case Halopridol, which is a safe drug, can be used instead of benzodiazepines.
– In case of gastrointestinal bleeding, an NG TUBE should be placed and the blood in the stomach should be washed out, and the blood in other parts of the digestive system should be drained by using laxatives and, if necessary, enema to reduce the nitrogen load.
– Protein should be removed from the diet
– Constipation should be prevented, for this purpose lactulose is used in the amount of 60 cc in 2 to 3 daily doses.
– If benzodiazepines cause it Hepatic encephalopathy Flumazenil is helpful.
Synthetic disaccharides (lactulose) and antibiotics (neomycin, rifaximin and metronidazole) can be used to reduce and inhibit the production and absorption of ammonia.
– You can also use drugs that stimulate ammonia metabolism, such as Ornithine-aspartate and Sodium benzoate.