HEPATIC ENCEPHALOPATHY

1. CHIEF COMPLAINT
a. Hepatic encephalopathy

2. HPI

3. ROS

4. SYMPTOMS
a. Shortened attention span
b. Impaired addition or subtraction
c. Hypersomnia
d. Insomnia
e. Euphoria
f. Depression
g. Irritability
h. Confusion
i. Slowing of ability to perform mental tasks
j. Asterixis
k. Lethargy
l. Apathy
m. Disorientation
n. Inappropriate behavior
o. Slurred speech
p. Drowsiness
q. Amnesia
r. Fits of rage
s. Coma with or without response to painful stimuli

5. HISTORY
a. FAMILY HISTORY
b. SOCIAL HISTORY
•Alcoholism
c. PASTMEDICAL HISTORY
d. SURGICAL HISTORY
e. CHRONIC CONDITIONS
•Hepatitis
•Cirrhosis

6. ALLERGIES

7. PHYSICAL EXAMINATION
8. SPECIFIC DATA LIKE GRADING ETC

•Grade 0 - Minimal hepatic encephalopathy. Lack of detectable

changes in personality or behavior. Minimal changes in memory,
concentration, intellectual function, and coordination. Asterixis is
absent.
•Grade 1 - Trivial lack of awareness. Shortened attention span.
Impaired addition or subtraction. Hypersomnia, insomnia, or
inversion of sleep pattern. Euphoria, depression, or irritability.
Mild confusion. Slowing of ability to perform mental tasks.
Asterixis can be detected.
•Grade 2 - Lethargy or apathy. Disorientation. Inappropriate
behavior. Slurred speech. Obvious asterixis. Drowsiness, lethargy,
gross deficits in ability to perform mental tasks, obvious
personality changes, inappropriate behavior, and intermittent
disorientation, usually regarding time.
•Grade 3 - Somnolent but can be aroused, unable to perform
mental tasks, disorientation about time and place, marked
confusion, amnesia, occasional fits of rage, present but
incomprehensible speech
•Grade 4 - Coma with or without response to painful stimuli.

9. TESTS TO BE ORDERED
•CBP
•Serum electrolytes
•Serum bilirubin
•Liver function tests
•Serum creatinine
•Blood ammonia
•EEG
•X-ray
•USG abdomen
•CT scan
•MRI

10. ASSSSMENT /PLAN

•Exclude nonhepatic causes of altered mental function.

•Patients with severe agitation and hepatic encephalopathy may
receive haloperidol as a sedative.

11. EDUCATION
 •Avoid medications that depress central nervous system function,
especially benzodiazepines.
•Take diets containing vegetable proteins
•Consume well-cooked chicken and fish in addition to vegetable
protein.
•Take commercially available liquid nutritional supplements in
diet.

12. MEDICATION
•Lactulose
•Lactilol
•Neomycin
•Metronidazole
•Vancomycin
•Paromomycin
•Quinolones
•Rifaximin
•L-ornithine L-aspartate (LOLA)
•Zinc sulfate
•Zinc acetate
•Sodium benzoate
•Sodium phenylbutyrate
•Sodium phenylacetate
•L-carnitine
•Hydroxyzine

13. FOLLOW-UP