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Hepatic

Encephalopathy
Chenyu Zhu M.D.
Emory University
Department of Medicine
Division of Digestive Diseases
Key Points:
Epidemiology:
Pathogenesis:
Precipitating Factors:
Stages:
Abdominal swelling.
Nausea ,vomiting.
Dark urine.
Sleep disturbances.
Caput Medusa.
Fetor hepaticus
Jaundice, itching
Hepatomegaly, splenomegaly.
Flapping tremors.
Gynecomastia.
Melena , fatigue.

Physical Exam:
Labs:
Radiology:
Head MRI:
PVWM, thalami, and corticospinal tract abnormalities on
FLAIR and DWI

Ab CT/MRI
Signs of portal hypertension and liver pathologies

Ab Ultrasound
Can be useful in emergent cases, but low
sensitivity/specificity
Therapeutic Goals
Lactulose, 20 60 mL TID
Inhibits intestinal bacterial, decreasing nitrogen load
Neomycin 1g/6hrs
Metronidazole 400 mg/6hrs

Contraindications:
Excess diuretics
Sedatives and Hypnotics
Hepatotoxic drugs

Prescriptions
Therapeutic parameters
Bloodwork
Serum ammonia
Chem 14; sp Na, K, Albumin, AST, ALT, Cr, BUN

Clinical Parameters
Improving MMSE
Stable vitals
Improvement of clinical symptoms

Case Presentation:
HPI: 62 y/o AAF presents to the ED with increasing
confusion reported by spouse beginning yesterday night.
Spouse also reports disorientation, lethargy, abdominal pain
and constipation. Was discharged 4 days prior for CHF
exacerbation

PMHx:
DM on OHG agent
CHF, NYHA stage III
HCV, HBV
Portal HTN

FHx: Non significant
Case Presentation, cont:
SHx
Married 30 years, previous sex worker, previous alcohol
dependent, clean 3 years

Medications
Gliprimide 3mg PO OD
Meformin 500mg PO BID
Furosemide 40mg PO OD
Lactulose 30mL PO TID
ED
Vitals:
RR: 22 BP: 135/78 P: 75 bpm T: 36.2
Labs:
Na: 144 K 4.1 Cr: 100 Glu: 12.1 Alb: 22
AST: 100 ALT: 69 Bili: 7
CK: 2468 Troponin: 1.6 GGT: 92
Physical Exam:
Gen: Disoriented, Confused, Sleep, Easily woken
Skin: No rash, no jaundice
CVS: RRR no G/R/M, pulse equal B
Pulm: B basilar crackles, no R/R
Ab: distended, soft, hepatomegaly, mild ascites
CNS: Flapping tremors bilaterally

Assessment and Plan:
Assessment: 62 y/o AAF discharged 4 days prior for CHF
exacerbation presenting with stage III hepatic
encephalopathy likely 2/2 furosemide d/c. History of
portal HTN and HBV and HCV
Plan:
Labs:
CBC, LFTs, aPTT, U&E. PCR HBV and HCV DNA
Meds
Furosemide 40 IV BID
Lactulose 30 mL PO TID
Lactulose enema 300 mL PR OD
Ceftriaxone 2 g IV OD
SSI