See Acute Liver Failure
|Hepatic Encephalopathy: Management|
Treat any factors that have caused the HE episode.
Low protein diet. Pabrinex acutely
Exclude spontaneous bacterial peritonitis and sepsis
Lactulose 15-30 ml TDS to give 2-3 bowel motions/day
Rifaximim 400 mg TDS PO
- Hepatic encephalopathy (HE) seen with advanced, acute or chronic liver disease
- Portosystemic encephalopathy (PSE)
- It is one of the major complications of cirrhosis.
- Can occur in acute and chronic liver disease.
- Blood bypasses the liver to pass directly to the brain
- The long term aim of HE treatment is to reduce the production and absorption of toxins such as ammonia.
- Mild confusion, forgetfulness, personality or mood changes
- Stale or sweet odour on the breath, poor judgement
- Poor concentration, reversal and change in sleep patterns
- Worsening of handwriting or small hand movements
- Severe symptoms may include: liver flap (asterixis), extreme anxiety
- Seizures, severe confusion, sleepiness or fatigue
- Severe personality changes, jumbled and slurred speech
Asterixis - a negative myoclonus
Grades of Encephalopathy
- Grade 1 Disorienated
- Grade 2 Confused
- Grade 3 Comatose
- Grade 4 Coma
- FBC WCC / ESR / CRP
- AST elevated ALT elevated (they fall eventually) Prothrombin time ?
- Creatinine: AKI, Check Na and K
- Urea : if high consider GI bleed if creatinine stable
- Ammonia levels are not a great correlate with encephalopathy
- pH - metabolic acidosis and arterial lactate
- Paracetamol level if possible cause
- Doppler of hepatic veins for Budd Chiari syndrome
- CXR, Urinalysis, Sample ascitic fluid for SBP
- OGD if upper GI bleed suspected
Look for and manage any Precipitants
- Infection/sepsis - chest, urine, SBP
- Postosystemic shunting, Infection,Low K
- Sedatives, hepatotoxic drugs,antidepressants
- Paracentesis, diuretics, Sedation
- Dehydration, Constipation,High Protein load/GI bleed
- GI Bleed - gastritis or variceal bleed
- Alcohol binge, AKI
- Hypoglycaemia, Post ictal state
- Head injury, SDH or ICH
- Drug or alcohol intoxication
- Delirium tremens, Primary psychiatric disorders
Management (see Acute Liver failure)
- This is a treatable condition however the severity of the condition and any causes of the episode will determine the treatment that a person will be given. Liaise with the local liver centre. Some may need transfer for management or transplant.
- Identify and then treat any factors that have caused the HE episode.
- Lactulose 30 mls BD to enable 2-3 soft bowel movements per day
- Neomycin up to 4 g /day in divided doses usually for 5-7 days reduces gut flora
- Rifaximin 400 mg TDS mg twice daily Reduction in recurrence of hepatic encephalopathy is taken long term
- Certain medications broken down by the liver such as sedatives and tranquilisers should be avoided.
- Consider IV Vitamin K if prothrombin time prolonged