Hepatic enchepalopathy

• Neuropsychiatric syndrome caused by liver disease.

• Precipitating factors:
1. Drugs(esp sedatives and antidepressants)
2. Dehydration(diuretics and paracentesis)
3. Portosystemic shunting
4. Infection
5. Hypokalemia
6. Constipation
7. Increased protien load(including GI bleeding)
• Clinical grades:
 Grade 1- poor concentration, slow mentation,
slurred speech and disturbed sleep rhythm.
 Grade 2- drowsy but easily rousable, occasional
aggressive behaviour and lethargy
 Grade 3- drowsy, delirium, disoriented grossly
and sleepy but responds to pain and stimuli.
 Grade 4- unconsious, unresponsive to voice but
may or mayn’t respond to pain.
• On examination:
1. Flapping tremors( aterixis)
2. Inability to perform simple mental arithmetic task or to
draw objects such as a star(constructional apraxia)
3. Fetor hepaticus: a sweet musty odor.
• Pathophysiology:
d/t disturbance in brain function triggered by circulating
neurotoxins(nitrogenous substances; ammonia mainly),
that are normally metabolised by liver. Those neurotoxins
are produced in gut, by bacteria.
• Investigations:
Diagnosis is made clinically, when doubt exists;
1. Electroenchephalogram: diffuse slowing of alpha waves with
eventual development of delta waves.
2. Arterial ammonia: increased.
• t/t:
 Lactulose is increased gradually until bowels are moving twice
daily.
 Rifaximin
 In chronic or refractory cases: liver transplantation.
 Treat or remove precipitating factors.