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Clinical Alimentary System > 3.5. Liver + Biliary Tree Disease - Portosystemic Encephalopathy > Flashcards

3.5. Liver + Biliary Tree Disease - Portosystemic Encephalopathy Flashcards

1
Q

What is Portosystemic Encephalopathy?

A

This is a neuropsychiatric condition

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2
Q

What is Encephalopathy?

A

Irritation of the Brain

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3
Q

What is Portosystemic Encephalopathy secondary to?

A

Liver Cirrhosis / Hepatic Failure

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4
Q

What are the main predisposing factors to Portosystemic Encephalopathy?

A
  1. Gastrointestinal Haemorrhage
  2. Constipation
  3. Infection
  4. Drugs
  5. Fluid/Electrolyte Disturbances
  6. Surgical Procedures
  7. Toxic Substances
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5
Q

In which Group of people is Constipation a common source of Portosystemic Encephalopathy?

A

The Elderly

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6
Q

What infections can cause Portosystemic Encephalopathy?

A
  1. Urinary Tract Infections - These are the most common
  2. Chest Infection (URTI/LRTI)
  3. Spontaneous Bacterial Peritonitis - this must be rules out as a cause
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7
Q

What type of drugs can lead to Portosystemic Encephalopathy?

A

Central Nervous System Depressants

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8
Q

What can cause Fluid / Electrolyte Disturbances?

A
  1. Diuretic Therapy

2. Paracentesis

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9
Q

What Surgical Procedure, used in the Liver, can commonly lead to Portosystemic Encephalopathy?

A

Transjugular Intrahepatic Portocaval Shunt (TIPS)

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10
Q

What Toxic substances, in high levels, may be a causative factor?

A
  1. Ammonia
  2. Free Fatty Acids
  3. Thiols
  4. False Neurotransmitters (e.g. Octopamine)
  5. The activation of the Gamma-Aminobutyric Acid System (An inhibitory neurotransmitter)
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11
Q

What is the Pathology of Portosystemic Encephalopathy?

A
  1. The exact mechanism is unknown, but it is multifactorial
  2. Due to the Aetiology, Toxins are not deal with properly by the Liver
  3. These allow the Toxins to remain in the Blood which will irritate the Brain
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12
Q

What are the Clinical Signs of Portosystemic Encephalopathy?

A
  1. Asterixis (Hepatic Flap)
  2. Fetor Hepaticus
  3. Decreased Blood Pressure
  4. Decreased Blood Glucose
  5. Decrease Blood Urea
  6. Decreased Mental Function
  7. Confusion to Coma
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13
Q

What is Asterixis?

A

A flapping tremor caused by Hepatic Failure

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14
Q

What is Fetor Hepaticus?

A

Sweet Smelling Breath

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15
Q

Why does Fetor Hepaticus occur in Portosystemic Encephalopathy?

A

Portosystemic Shunting allows Thiols into the Lungs

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16
Q

Why might there be a Decrease in Blood Pressure / Urea?

A

If the patient goes into Renal Failure as a result of the Aetiology

17
Q

Why might there be a Decrease in Blood Glucose?

A

Due to the Liver being damaged, and so unable to release the Glucose stored in it

18
Q

How might the Decrease in Mental Function present?

A
  1. Drowsiness
  2. Constructional Apraxia
  3. Hyperreflexia
  4. Increased Tone
19
Q

What is Constructional Apraxia?

A

The patient being unable to write / draw

20
Q

What are Hyperreflexia and Increased Tone examples of?

A

Upper Motor Neuron Signs

21
Q

Why might Upper Motor Neuron Signs occur?

A

Due to the irritation and effect on the Central Nervous System and the Brain

22
Q

How is the Decreased Mental Function graded?

A

Grade 1 - Impaired Concentration
Grade 2 - Disorientation
Grade 3 - Confusion / Amnesia
Grade 4 - Coma

23
Q

What are the Symptoms of Portosystemic Encephalopathy?

A
  1. Asymptomatic
  2. Infectious Markers (Fever, Nausea/Vomiting…)
  3. Psychogenic changes
24
Q

When would Infectious Markers be present?

A

If an infection was the cause

25
Q

What Psychogenic changed might occur?

A
  1. Irritability
  2. Confusion
  3. Disorientation
  4. Slow Slurred Speech
26
Q

What investigations are required for Portosystemic Encephalopathy?

A
  1. Liver Function Test (and Biochemistry)
  2. Electroencephalography (EEG)
  3. Visually Evoked Responses
  4. Arterial Blood Ammonia
27
Q

What are Liver Function Tests (and Biochemistry) Looking for?

A

Liver Function Test:

  1. Prothrombin Time
  2. Serum Albumin

Liver Biochemistry:

  1. Bilirubin
  2. Alkaline Phosphatase
  3. Gamma-Glutamyl Transpeptidase
  4. Aminotranferases:
    a) Aspartate Aminotransferase
    b) Alanine Aminotransferase
28
Q

What is the purpose of the Liver Function Tests (and Biochemistry)?

A

To find the presence of Liver Disease

29
Q

What is the purpose of Electroencephalography (EEG)?

A

To view the damage to the Brain

30
Q

What will be shown on an Electroencephalography before a Coma occurs?

A

A decrease in the Frequency of Normal Alpha Waves

31
Q

What do Visually Evoked Responses detect?

A

Subclinical Encephalopathy

32
Q

What is the Purpose of Arterial Blood Ammonia?

A

To identify the cause of the irritation to the Brain

33
Q

What is the Treatment of Portosystemic Encephalopathy?

A

To treat the underlying cause

34
Q

How do you treat the underlying Infection?

A

Antibiotics

35
Q

How do you treat the underlying Constipation?

A
  1. Laxatives (Dextrose / Lactulose)

2. Enema

36
Q

How do you treat the underlying Electrolyte Disturbance?

A

Potassium Supplements

37
Q

How do you treat the underlying Renal Failure?

A

Dialysis - this can also be used for severe hepatic failure

38
Q

What general measures might be taken?

A

Nasogastric Tube - for medication

39
Q

If the patient enters into a Coma, what will be required?

A
  1. Ventillation

2. I.V. access - for medication and nutrition

Clinical Alimentary System (64 decks)

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