Hepatic Encephalopathy UMASS ECHO Curtis Barry MD March

Hepatic Encephalopathy UMASS ECHO Curtis Barry, MD March 31, 2017

HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy

Definitions • Hepatic Encephalopathy • Potentially reversible neuropsychiatic abnormalities seen in patients with liver dysfunction or porto-systemic shunting • Minimal Hepatic Encephalopathy • Subclinical encephalopathy in patients with liver dysfunction, only detectable with specialized neuropsychiatric tests

Epidemiology • 30 -45% of patients with decompensated cirrhosis have HE • 20% annual risk of development in patients with compensated cirrhosis • 60 -80% of patients with compensated cirrhosis have evidence of minimal HE

PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy Pathogenesis Toxins NH 3 Shunting Failure to metabolize NH 3 Bacterial action Protein load GABA-BD receptors

STAGES OF HEPATIC ENCEPHALOPATHY Stages of Hepatic Encephalopathy Stage Mental state Neurologic signs 1 Mild confusion: limited attention span, irritability, inverted sleep pattern Incoordination, tremor, impaired handwriting 2 Drowsiness, personality changes, intermittent disorientation Asterixis, ataxia, dysarthria 3 Somnolent, gross disorientation, marked confusion, slurred speech Hyperreflexia, muscle rigidity, Babinski sign 4 Coma No response to pain, decerebrate posture

HEPATIC ENCEPHALOPATHY IS A CLINICAL DIAGNOSIS Hepatic Encephalopathy Is A Clinical Diagnosis · Clinical findings and history important · Ammonia levels are unreliable · Ammonia has poor correlation with diagnosis · Measurement of ammonia not necessary · Number connection test · Slow dominant rhythm on EEG

Stroop App

Hepatic Encephalopathy Precipitants Sedatives / hypnotics Excess protein GI bleeding TIPS Diuretics Serum K+ Plasma volume Temp Infections Azotemia

TREATMENT OF HEPATIC ENCEPHALOPATHY Treatment of Hepatic Encephalopathy · Identify and treat precipitating factor · Infection · GI hemorrhage · Prerenal azotemia · Sedatives · Constipation · Lactulose (adjust to 2 -5 bowel movements/day) · RIFAXIMIN

ACTIONS OF LACTULOSE Actions of Lactulose NH 3 Decreased p. H NH 4+ Lactic acid NH 3 Lactulose Urease-producing bacteria Increase cathartic effect