Updated: 6/20/2019

Hepatic Encephalopathy

Topic
Review Topic
0
0
Questions
4
0
0
Evidence
4
0
0
Videos
1
Snapshot
  • A 50-year-old man with cirrhosis is brought to the emergency room for altered mental status. He lives at home with his mother, who noted that he was slow in his responses and disoriented. He has a history of alcoholic cirrhosis, and for the past week he has not eaten much food. His last drink was a day ago. On physical exam, he is noted to be jaundiced with asterixis. His mucous membranes are dry and his capillary refill is delayed. An ultrasound of his abdomen shows ascites. Labs are significant for hyperkalemia and elevated ammonia to 200 μmol/L. He is started on lactulose and rifaximin and admitted to the inpatient unit for further management.
Introduction
  • Overview
    • a reversible complication of liver failure characterized by altered mental status and asterixis
    • often precipitated by acute stressors such as dehydration or infection
  • Epidemiology
    • incidence
      • 30-40% of patients with cirrhosis
    • risk factors
      • alcohol use
      • hepatitis
  • Etiology
    • acute triggers
      • dehydration
      • infection
      • gastrointestinal bleed
      • fluid and electrolyte abnormalities
      • sedatives
      • hepatocellular carcinoma
      • transjugular intrahepatic portosystemic shunt (TIPS)
  • Pathogenesis
    • mechanism
      • ↓ ammonia clearance due to liver dysfunction
        • ammonia is normally metabolized in the liver to urea, which is easily excreted
      • portosystemic shunts causing blood to bypass the liver
      • ammonia is neurotoxic
        • crosses blood-brain barrier and is converted to glutamine, which is an osmolyte and promotes swelling of brain cells
        • this leads to cerebral edema
  • Associated conditions
    • acute liver failure
    • cirrhosis
      • other complications of cirrhosis include portal hypertension, esophageal varices, and hepatocellular carcinoma
  • Prognosis
    • hepatic encephalopathy is reversible
Classification
  • Classification by underlying disease
    • type A
      • acute liver failure
    • type B
      • portosystemic bypass or shunting with preserved liver function
    • type C
      • cirrhosis
Presentation
  • Symptoms
    • common symptoms
      • mood changes
      • slow to respond
      • unsteadiness
  • Physical exam
    • inspection
      • signs of liver disease
        • jaundice
        • ascites
        • spider angiomata
        • palmar erythema
      • asterixis
        • flapping tremor of wrists
      • altered mental status
      • coma/stupor in severe cases
Imaging
  • CT or MRI of the head
    • indication
      • rule out intracranial hemorrhage or mass as a cause of encephalopathy
    • findings
      • cerebral edema
Studies
  • Serum labs
    • ↑ ammonia
    • also check
      • liver function panel
      • blood urea nitrogen
      • electrolytes
Differential
  • Other metabolic encephalopathies
    • diabetic ketoacidosis
      • distinguishing factor
        • hyperglycemia with ketones in the blood and anion gap metabolic acidosis
    • uremic encephalopathy
      • distinguishing factor
        • elevated urea and normal ammonia
    • acute alcoholic intoxication
      • distinguishing factor
        • elevated blood alcohol level
Treatment
  • Nonoperative
    • correct precipitating factor and electrolyte derangements 
    • lactulose  
      • mechanism
        • gastrointestinal flora degrades lactulose into lactic acid and acetic acid, which results in the clearance of ammonia
      • indication
        • treatment and prevention
    • rifaximin
      • mechanism
        • ↓ bacteria that produce ammonia
      • indication
        • treatment and prevention alongside lactulose
Complications
  • Persistent learning impairment
 

Please rate topic.

Average 5.0 of 4 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

You have 100% on this question.
Just skip this one for now.

(M2.GI.4684) A 56-year-old woman with a history of alcoholic cirrhosis and recurrent esophageal varices who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement is brought to the emergency room by her daughter due to confusion and agitation. Starting this morning, the patient has appeared sleepy, difficult to arouse, and slow to respond to questions. Her temperature is 97.6°F (36.4°C), blood pressure is 122/81 mmHg, pulse is 130/min, respirations are 22/min, and oxygen saturation is 98% on room air. She repeatedly falls asleep and is combative during the exam. Laboratory values are notable for a potassium of 3.0 mEq/L. The patient is given normal saline with potassium. Which of the following is the most appropriate treatment for this patient? Review Topic

QID: 107354
1

Ciprofloxacin

0%

(0/0)

2

Lactulose

0%

(0/0)

3

Nadolol

0%

(0/0)

4

Protein-restricted diet

0%

(0/0)

5

Rifampin

0%

(0/0)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2

You have 100% on this question.
Just skip this one for now.

(M3.GI.3) A 40-year-old man presents to the emergency department with altered mental status. He has a history of cirrhosis of the liver secondary to alcoholism. He started becoming more confused a few days ago and it has been getting gradually worse. His temperature is 98.8°F (37.1°C), blood pressure is 134/90 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended abdomen that is non-tender. Neurological exam is notable for a confused patient and asterixis. Laboratory values are ordered as seen below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.3 mEq/L
HCO3-: 22 mEq/L
BUN: 20 mg/dL
Glucose: 59 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the best next treatment for this patient?
Review Topic

QID: 102619
1

Ceftriaxone

17%

(1/6)

2

Dextrose

33%

(2/6)

3

Lactulose

17%

(1/6)

4

Potassium

17%

(1/6)

5

Rifaximin

17%

(1/6)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4

You have 100% on this question.
Just skip this one for now.

(M2.GI.4694) A 56-year-old male with a history of hepatitis C cirrhosis status post TIPS procedure is brought in by his wife to the emergency department because he has been acting disoriented, slurring his speech, and sleeping throughout the day. On arrival the patient is afebrile and his vital signs are pulse is 87/min, blood pressure is 137/93 mmHg, and respirations are 12/min with shallow breaths. Examination reveals a jaundiced male who appears older than stated age. Abdominal exam is positive for a fluid wave and shifting dullness to percussion. You note enlarged breasts, decreased facial hair, 3+ patellar reflexes bilaterally, and the following in the upper extremity (Video A). Paracentesis reveals ascitic fluid with neutrophil counts of < 100 cells/mcL. Serum creatinine is 1.0 and BUN is 15. Which of the following is the next best step in management? Review Topic

QID: 107840
FIGURES:
1

IV albumin and antibiotic therapy with cefotaximine

67%

(2/3)

2

Liver transplantation

0%

(0/3)

3

Adminsiter rifaximin and glucose

0%

(0/3)

4

Administer lactulose

33%

(1/3)

5

Administer neomycin and glucose

0%

(0/3)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4

You have 100% on this question.
Just skip this one for now.

(M2.GI.33) A 52-year-old male with a history of chronic hepatitis C presents to the emergency department with his wife. His wife states that she is very concerned because she thinks that he "isn't thinking straight." She states that he awoke this morning and did not appear to know where he was. She also states that over the past 2 days he developed a productive cough and fever. On exam, the patient appears altered and his vitals are shown as Temp: 38 deg C, HR: 77 bpm, BP: 134/98 mmHg, RR: 12, SaO2: 97%. The physician observes the findings shown in Figure A and Figure B. Furthermore, when the patient holds his hands as demonstrated in Figure C, they oscillate as though he is slapping the air. A chest radiograph is obtained, which is demonstrated in Figure D. In addition to appropriate antibiotic therapy, what other medication should be initiated in this patient? Review Topic

QID: 104824
FIGURES:
1

Albumin

0%

(0/24)

2

Metronidazole

0%

(0/24)

3

Lorazepam

0%

(0/24)

4

Lactulose

96%

(23/24)

5

Emergent liver transplant

0%

(0/24)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4
ARTICLES (4)
VIDEOS & PODCASTS (1)
Topic COMMENTS (9)
Private Note