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Updated: Dec 15 2021

Hepatic Encephalopathy

  • 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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