Updated: 12/15/2021

Hepatic Encephalopathy

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  • 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
    • 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
    • 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)
  • 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
  • Prognosis
    • Hepatic encephalopathy is reversible
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Questions (6)

(M2.GI.17.4684) 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?

QID: 107354

Ciprofloxacin

0%

(0/7)

Lactulose

100%

(7/7)

Nadolol

0%

(0/7)

Protein-restricted diet

0%

(0/7)

Rifampin

0%

(0/7)

M 6 D

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(M2.GI.16.4694) 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?

QID: 107840
FIGURES:

IV albumin and antibiotic therapy with cefotaximine

18%

(2/11)

Liver transplantation

0%

(0/11)

Adminsiter rifaximin and glucose

0%

(0/11)

Administer lactulose

82%

(9/11)

Administer neomycin and glucose

0%

(0/11)

M 7 E

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(M2.GI.15.33) 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?

QID: 104824
FIGURES:

Albumin

0%

(0/31)

Metronidazole

0%

(0/31)

Lorazepam

3%

(1/31)

Lactulose

94%

(29/31)

Emergent liver transplant

0%

(0/31)

M 7 B

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(M3.GI.12.3) 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?

QID: 102619

Ceftriaxone

7%

(1/15)

Dextrose

20%

(3/15)

Lactulose

40%

(6/15)

Potassium

27%

(4/15)

Rifaximin

7%

(1/15)

M 11 E

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