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Hepatic Encephalopathy

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Hepatic Encephalopathy

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Hepatic Encephalopathy

  1. 1. 1
  2. 2. complex organic brain syndrome characterized by disturbances in consciousness, fluctuating neurologic signs, asterixis/“flapping tremor” and distinctive electroencephalographic changes. 2
  3. 3. 3
  4. 4. 4
  5. 5. Chronic parenchymal liver disease: ◦Chronic hepatitis ◦Cirrhosis(30-45%).  Fulminating hepatic failure: Acute viral hepatitis Drugs-sedatives sedative antipsychotics alcohol intoxication Toxins e.g. Wilson’s Disease 5
  6. 6. Surgical -Portal-systemic anastomoses, - portacaval shunts, or Transjugular intrahepatic portal-systemic shunting [TIPS](10-15%). Excessive nitrogen load- excess protein consumption, gastro-intestinal bleeding, renal failure, constipation. Electrolyte or metabolic disturbance-hypokalaemia, hyponatremia, alkalosis, dehydration, excess vomiting. Infections- pneumonia, UTI, spontaneous bacterial peritonitis. Unknown- 20-30% 6
  7. 7. Shunting of portal blood directly into systemic circulation bypassing liver. Severe hepatocellular damage and dysfunction. toxic substances absorbed from intestine not metabolised by liver toxins accumulate in the brain 7
  8. 8. Diminished detoxification of toxic intestinal nitrogenous compounds 8 Increased in blood NH3 etc Toxic effect on brain Appearance of abnormal amines in systemic circulation Interference with neurotransmission
  9. 9. transamination (catalysed by aminotransferases) oxidative deamination (catalyysed by L-amino acid oxidase) 9
  10. 10. Normally, ammonia is detoxified in the liver by conversion to urea by the Krebs cycle Ammonia is also consumed in the conversion of glutamate to glutamine, a reaction that depends upon the activity of glutamine synthetase. 10
  11. 11. decreased mass of functioning hepatocytes - fewer opportunities for ammonia to be detoxified by the above processes portosystemic shunting may divert ammonia- containing blood away from the liver to the systemic circulation. 11
  12. 12. Ammonia crosses the blood–brain barrier - absorbed and metabolised by the astrocytes (cells in the brain that constitutes 30% of the cerebral cortex)  Astrocytes use ammonia when synthesising glutamine from glutamate. Increased levels of glutamine - increase in osmotic pressure in astrocytes - swelling of astrocytes. 12
  13. 13. star-shaped cells in the brain, which helps maintain proper composition of the fluid surrounding the neurons. The only cerebral cell capable of metabolizing ammonia. In HE, they adopt a characteristic morphologic feature known as ‘Alzheimer type II astrocytosis’ 13
  14. 14. Disturbance in consciousness disturbance in sleep pattern hypersomnia-earliest feature impaired memory mental confusion Drowsiness coma 14
  15. 15. Changes in personality childish behaviour irritability loss of concern for family aggressive outburst euphoria defaecation and micturating in inappropriate places Fetor hepaticus 15
  16. 16. Fluctuating Neurological Exam Findings: Slurred speech Constructional apraxia Hypertonia Flapping tremor/ Asterixis Exaggerated tendon reflexes Bilateral extensor plantar reflex 16
  17. 17. Sour, musty breath due to volatile substances normally formed in the stool by bacteria. These mercaptans if not removed by the liver are excreted through the lungs and appear in the breath. Fetor hepaticus does not correlate with the degree or duration of encephalopathy and its absence does not exclude Hepatic Encephalopathy. 17
  18. 18. 18 Connect –The Numbers Test
  19. 19. Due to impaired inflow of joint and other afferent information to the brainstem resulting in lapses in posture. Arms outstretched and fingers separated/ hyperextending the wrists with the forearm fixed. The rapid flexion-extension movements of the metacarpophalangeal and wrist joints with lateral movements of the digits. Usually bilateral but not synchronous 19
  20. 20. 20
  21. 21. Neurology: subdural hematoma, intracranial bleeding, stroke, tumor, and abscess Toxic: alcohol intake, alcohol withdrawal, and Wernicke encephalopathy, sedative hypnotics, antidepressants, antipsychotic agents, and salicylates Metabolic: hypoglycemia, electrolyte imbalance, anoxia, hypercarbia, and uremia Infection: meningitis, encephalitis & intracranial abscess Hyperammonemia: from ureterosigmoidostomy and inherited urea cycle disorders Postseizure encephalopathy 21
  22. 22. By exclusion 22
  23. 23. No Pathognomonic liver function abnormality Elevation of blood ammonia-in 90% cases. Hypokalaemia EEG CSF & CT Scan Labs: abnormal liver function tests, ultrasound of the liver, and liver biopsy 23
  24. 24. Decreasing ammonia production in the colon treatment of precipitating factors 24
  25. 25. Ensure BO 3-4x per day – Lactulose 15-30ml Antibiotics : Rifaximin-only used as a 2nd line treatment if lactulose is not effective or poorly tolerated. When added to lactulose, the combination of the two may be more effective than each component separately. 25
  26. 26. 26
  27. 27. Brain herniation/ Brain swelling Increased risk of: ◦Cardiovascular collapse ◦Kidney failure ◦Respiratory failure ◦Sepsis Permanent nervous system damage Progressive, irreversible coma 27
  28. 28. Harrison’s Medscape Oxford Handbook of General Medicine http://crisbertcualteros.page.tl 28

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