HEPATIC HEPATIC ENCEPHALOPATHYENCEPHALOPATHY

Dr. Bindu MohandasDr. Bindu Mohandas

M-5 unitM-5 unit

SYNONYMSSYNONYMS

Portosystemic encephalophathyPortosystemic encephalophathy

Hepatic coma Hepatic coma

Incidence: 71% in cirrhosisIncidence: 71% in cirrhosis

DEFINITIONDEFINITION

Hepatic Encephalopathy is a Hepatic Encephalopathy is a neuropsychatric syndrome caused by liver neuropsychatric syndrome caused by liver disease, characterised by disturbances in disease, characterised by disturbances in conciousness level & behaviour, personality conciousness level & behaviour, personality changes, fluctuating neurological signs, changes, fluctuating neurological signs, asterixis & distinctive EEG changes.asterixis & distinctive EEG changes.

TYPESTYPES

Acute/ Subacute Acute/ Subacute Reversible Reversible

ChronicChronic Progressive Progressive leading to irreversible leading to irreversible coma & coma & death death

Factors Precipitating Factors Precipitating hepatic encephalopathyhepatic encephalopathy

Increased Protein Load (nitrogen) – Increased Protein Load (nitrogen) – GI bleeding, excessive dietary GI bleeding, excessive dietary protein, uremia, constipationprotein, uremia, constipation

Drugs – Sedatives, AntidepressantsDrugs – Sedatives, Antidepressants Dehydration – Diuretics, paracentesis Dehydration – Diuretics, paracentesis Trauma – including surgeryTrauma – including surgery Electrolyte imbalance – hypokalemia, Electrolyte imbalance – hypokalemia,

alkalosis, hypovolemiaalkalosis, hypovolemia Large binge of alcoholLarge binge of alcohol

ETIOPATHOGENESISETIOPATHOGENESISAbnormality in nitrogen metabolism by urease producing bacteria in Abnormality in nitrogen metabolism by urease producing bacteria in

bowel.bowel.

Accumulation of ammonia, octapamine aminoacid, fatty acid, mercaptans.Accumulation of ammonia, octapamine aminoacid, fatty acid, mercaptans.

Carried to liver by portal circulation.Carried to liver by portal circulation.

Fail to get detoxified due to hepatocellular disease/ Porto systemic Fail to get detoxified due to hepatocellular disease/ Porto systemic shunting of blood.shunting of blood.

Enters the systemic circulation.Enters the systemic circulation.

Crosses the blood brain barrier.Crosses the blood brain barrier.

Accumulates in brain.Accumulates in brain.

Ammonia induced alteration in astrocyte glutamine & glutamate Ammonia induced alteration in astrocyte glutamine & glutamate concentrations.concentrations.

Altered neurotransmission & cerebral oedema. Altered neurotransmission & cerebral oedema.

CLINICAL FEATURESCLINICAL FEATURES

Apathy, inability to concentrate, confusion, Apathy, inability to concentrate, confusion, disorientation, drowsiness, slurring of speech disorientation, drowsiness, slurring of speech derangement of conciousnessderangement of conciousnessAltered sleep rhythmAltered sleep rhythmIncreased psychomotor activityIncreased psychomotor activityProgressive drowsiness, stupor & comaProgressive drowsiness, stupor & comaFocal / generalised seizuresFocal / generalised seizuresExaggeration of DTRExaggeration of DTRAsterixisAsterixisConstructional aparaxiaConstructional aparaxiaFetor hepaticusFetor hepaticusInability to perform simple arithmatic tasks & Inability to perform simple arithmatic tasks & change in handwriting.change in handwriting.

Clinical grading of hepatic Clinical grading of hepatic encephalopathyencephalopathy

StageStage Mental StatusMental Status AsterixisAsterixis EEGEEG

Grade IGrade I Poor conc, slurred speech, mild Poor conc, slurred speech, mild confusion disordered sleep confusion disordered sleep rhythmrhythm

+/-+/- UsuallyUsually

normalnormal

Grade IIGrade II Drowsy but arousable, lethargic, Drowsy but arousable, lethargic, moderate confusionmoderate confusion ++ AbnormAbnorm

alal

Grade Grade IIIIII

Marked confusion, sleepy but Marked confusion, sleepy but responds to pain & voiceresponds to pain & voice ++ AbnormAbnorm

alal

Grade Grade IVIV

Coma- unconscious, non Coma- unconscious, non responsiveresponsive

-- AbnormAbnormalal

INVESTIGATIONSINVESTIGATIONS

EEG – Shows high voltage, slow wave EEG – Shows high voltage, slow wave forms reduced alpha rhythm & forms reduced alpha rhythm & increased delta activity.increased delta activity.

Elevation of serum ammoniaElevation of serum ammonia

No pathognomonic liver function No pathognomonic liver function abnormalityabnormality

CT Brain & CSF analysis – NormalCT Brain & CSF analysis – Normal

USG AbdomenUSG Abdomen

MRI scan in stage IV shows cerebral MRI scan in stage IV shows cerebral oedemaoedema

MANAGEMENTMANAGEMENT

Treat/Remove the precipitating causesTreat/Remove the precipitating causesDietary protein restrictionDietary protein restrictionLactulose (15-30ml 8Lactulose (15-30ml 8thth hourly) or Lactitol hourly) or LactitolNeomycin (1-4g 4-6 hourly) or Ampicillin Neomycin (1-4g 4-6 hourly) or Ampicillin i.v mannitoli.v mannitolAvoid drugs – sedatives, diureticsAvoid drugs – sedatives, diureticsLiver transplantation – defenite RxLiver transplantation – defenite RxThe use of levodopa, bromocriptine, The use of levodopa, bromocriptine, ketoanalogues of aminoacid ketoanalogues of aminoacid & i-v infusion of aminoacids, & i-v infusion of aminoacids, haemoperfusionhaemoperfusion – role is unclear.– role is unclear.

PROGNOSISPROGNOSIS

** Hepatic encephalopathy is associated with Hepatic encephalopathy is associated with short survival in cirrhotic patients short survival in cirrhotic patients

** Factors worsening the prognosis areFactors worsening the prognosis are

11. . male sexmale sex

22. . Increased levels of S. bilirubin, alkaline Increased levels of S. bilirubin, alkaline phosphatase, Potassium, BUNphosphatase, Potassium, BUN

33. . Reduced albumin and prothrombin activityReduced albumin and prothrombin activity. .

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

Subdural haematomaSubdural haematoma

Drug or alcohol intoxicationDrug or alcohol intoxication

Delirium tremensDelirium tremens

Wernicke’s encephalopathyWernicke’s encephalopathy

Primary psychiatric disordersPrimary psychiatric disorders

HypoglycemiaHypoglycemia

Neurological Wilson’s diseaseNeurological Wilson’s disease

SOURCE OF SOURCE OF INFORMATIONINFORMATION

www.google.comwww.google.com

www.pubmed.comwww.pubmed.com

Harrison’s internal medicineHarrison’s internal medicine

Davidson’s Principle of MedicineDavidson’s Principle of Medicine

Alagappan’s practical manual Alagappan’s practical manual

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