Hepatic Encephalopathy

Question 1

Cause?

Answer 1

Liver disease of any cause –> excess absorption of ammonia + glutamine from bacterial breakdown of proteins in gut

Question 2

What procedure may precipitate it?

Answer 2

Transjugular intrahepatic portosystemic shunting (TIPS)

Question 3

Features?

Answer 3

(1) confusion, altered GCS
(2) asterixis
(3) constructional apraxia: inability to draw a 5-pointed star
(4) triphasic slow waves on EEG
(5) raised ammonia level (not commonly measured anymore)

Question 4

Grading?

Answer 4

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

Question 5

Precipitants?

Answer 5

(1) infection (SBP)
(2) GI bleed
(3) post transjugular intrahepatic portosystemic shunt
(4) constipation
(5) drugs: sedatives, diuretics
(6) hypokalaemia
(7) renal failure
(8) increased dietary protein (uncommon)

Question 6

First line medication?

Answer 6

Lactulose (laxative) –> NICE recommends rifaximin (abx) for secondary prophylaxis

Question 7

Management of recurrent encephalopathy episodes?

Answer 7

Lactulose + Rifaximin