Hepatic Encephalopathy

Question 1

What are 3 symptoms of overt HE?

Answer 1

1. Altered mental status
2. Fatigue
3. Coma

Question 2

What are 2 symptoms of sub clinical or minimal HE?

Answer 2

1. Mild cognitive impairment
2. Coordination declining

Question 3

What is the best marker for HE?

Answer 3

Ammonium

Question 4

Grade for encephalopathy: shortened attention span with mild asterixis or tremor and mild lack of awareness

Answer 4

1

Question 5

Grade for encephalopathy: Lethargic, is disoriented with inappropriate behavior. Obvious aterixis and slurred speech

Answer 5

2

Question 6

Grade for encephalopathy: somnolent but arousable, gross disorientation with bizarre behavior. Has muscular rigidity and clonus; hyperflexia

Answer 6

3

Question 7

Grade for encephalopathy: Coma with decerebrate posturing

Answer 7

4

Question 8

What are 4 precipitating factors of HE?

Answer 8

1. Therapy non-compliance
2. TIPS
3. Medications (benzodiazepines, narcotics)
4. Upper GI bleed

Question 9

True or false: you should restrict protein in HE

Answer 9

False

Question 10

What MOA do you want the medications to have to treat HE?

Answer 10

Decrease nitrogen load in the GI tract

Question 11

What are 2 treatments for HE?

Answer 11

1. Lactulose
2. Rifaximin

Question 12

What is the MOA of lactulose?

Answer 12

Cathartic; reduces nitrogen absorption in the GI due to increased transit

Question 13

What is lactulose metabolized to?

Answer 13

Acetic acid and lactic acid

Question 14

What is the dosing for lactulose?

Answer 14

30-45 mL (20-30 g) Q4-6

Question 15

How many bowel movements do you want for a titration of lactulose?

Answer 15

2-3 loose stool bowel movements daily

Question 16

For a retention enema what is the dose for lactulose?

Answer 16

300 mL lactulose + 700 mL saline

Question 17

What are 2 nonobvious symptoms of lactulose?

Answer 17

1. Hyponatremia
2. Hypokalemia

Question 18

What does rifaximin decrease?

Answer 18

Urease producing bacteria in the GI tract

Question 19

What is the dose for rifaximin?

Answer 19

550 mg BID

Question 20

What are 5 ADRs of Rifaximin?

Answer 20

1. Abdominal pain
2. Nausea
3. Flatulence
4. Dizziness
5. Headache

Question 21

What drug has better compliance?

Answer 21

Rifaximin

Question 22

What is selection for Rifaximin and lactulose depend on?

Answer 22

Insurance

Question 23

What are 6 causes of liver disease?

Answer 23

1. Alcoholic hepatitis
2. Fatty liver/MASH
3. Drug induced liver disease
4. Hepatitis
5. Hemochromatosis
6. Wilson’s disease

Question 24

What 3 major lesions can occur in alcoholic liver disease?

Answer 24

1. Fatty liver
2. Cirrhosis
3. Alcoholic lesions

Question 25

Alcoholic hepatitis is _____ hepatic inflammation

Answer 25

Acute

Question 26

What are 3 mechanisms of injury for alcoholic hepatitis?

Answer 26

1. Ethanol metabolism 2. Inflammation 3. Innate immunity

Question 27

What is the cardinal symptom of alcoholic hepatitis?

Answer 27

Acute jaundice

Question 28

What are 4 clinical presentations of alcoholic hepatitis?

Answer 28

1. Acute jaundice 2. Fever 3. New onset ascites 4. Hepatomegaly

Question 29

What does the modified discriminate function (mDF) score need to be in order to treat?

Answer 29

32

Question 30

What criteria allows for corticosteroids to be used?

Answer 30

1. mDF >32 2. Hepatic encephalopathy

Question 31

What corticosteroid is utilized for HE?

Answer 31

Prednisone (40 mg)

Question 32

What 4 things are contraindicated for the use of steroids?

Answer 32

1. Infection 2. GI bleed 3. Acute pancreatitis 4. Renal failure

Question 33

Pentoxifylline

Answer 33

TRENTAL

Question 34

What is the MOA of TRENTAL?

Answer 34

Phosphodiesterase inhibitor and decreased transcription of the TNF-a promoter

Question 35

True or false: pentoxifylline is used as second line therapy to steroids

Answer 35

True

Question 36

When are patients able to get a liver transplant?

Answer 36

If they have 6 months of documented alcohol abstinence