HEPATIC
ENCEPHALOPATHY
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
Liaquat University of Medical & Health Sciences,
Jamshoro
Definition
• It is a state of disordered CNS function,
resulting from failure of liver to detoxify
toxic agents because of hepatic
insufficiency and porto-systemic shunt.
Toxic Agents
• Ammonia NH 3
• Mercaptin
• Free Fatty Acids
Pathogenesis
Ammonia formed by protein breakdown in GIT
Liver  Converts NH3 into urea  Excreted by kidney
Pathogenesis
Ammonia formed by protein breakdown in
GIT
Liver  liver dysfunction (abnormal)  NH3 
Passes BBB  Hepatic encephalopathy.
Precipitating Agents
(A) Increase Nitrogen Load
(a) Constipation.
(b) Gastro intestinal bleeding.
(c) Excess dietary intake of protein &
fatty acids.
(d) Azotemia.
Precipitating Agents
(B) Infections & Trauma (Surgery).
(C) Electrolyte & Metabolic imbalance
• Hypokalemia.
• Alkalosis.
• Hypoxia.
• Hyponatremic.
Precipitating Agents
(D) Drugs
• Diuretics, Narcotics, Tranquilizers,
Sedatives.
Clinical Features
Symptoms
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Sleep disturbances.
Personality Changes.
Confusion.
Slurred Speech.
Deterioration.
Drowsiness.
Coma.
Fever, Nausea, Vomiting and Techypnea are
also common.
Clinical Features
Signs
• Fetar Hepaticus.
• Flapping Tremors or Asteritxis.
• Coma.
Clinical Staging
Stage-I
• Euphoria or Depression
• Mild Confusion
• Slurred Speech
• Disordered Sleep
Clinical Staging
Stage-II
• Moderate Confusion.
• Lethargy
Clinical Staging
Stage-III
• Marked Confusion.
• Incoherent Speech.
• Sleeping but Arrousable.
Stage-IV
• Coma.
Investigation
(1)
(2)
(3)
(4)
(5)
Liver function test.
Serum Electrolytes.
EEG.
Arterial Blood Ammonia.
Blood gases.
Management
General Measures
(1) Hospitalize the patient.
(2) Identify and remove the precipitating
factors.
(3) Stop or reduce the Diuretic Therapy.
(4) Correct any electrolyte imbalance.
(5) Reduce the ammonia (NH3) Load.
• Treat Constipation by Laxatives
Management
Drug
• Lactulose
Mechanism of Action
• It produces osmosis of water- Diarrhea.
• It converts NH3- NH4 that can be
excreted.
Treat the GIT & other
Infections
GIT- Infection
• Supers the normal flora of GIT with
• Metronidazole
• Vacomycin.
Other Infection
• Third generation ephalosporin
Variceal Bleeding
The collaterals at oesophagogastric
junction due to porto-systemic shunt one
known as oesophageal varices.
The varices can rupture in 1/3 cases and
can lead to death in 50% cases.
Clinical Feature
• Melena (black colour stools)
• Hematemis
• Hypovolumic shock
Management
Treatment during active-bleeding.
(1) Monitor the vitals
(2) Pass I/V line and give blood
transfusion.(if not available give plasma
expander).
(3) FFP (Fresh Frozen Plasma) can be
given in case of thrombocytopenia.
(4) I/V H2 receptor blocker or proton
pump inhibitors (Omeperazole) can be
given to reduce gastric irritation.
Vasoconstriction Agents
(1) Vasopression
• Side-effect - angina or MI.
(2) Terlepression
• More safe as compared to vasopression.
(3) Octreotide
• Also decreases secretion in GIT.
Urgent Endoscopy and
Sclerotherapy
• After stoppage of bleeding with the help of
vasoconstricting agent and when patient
becomes hemodynamically in stable condition,
then injection sclerotherapy can be given.
Urgent Endoscopy and
Sclerotherapy
• Sclerosing agent
Ethanolamine tetradecyl sulfate.
OR
Banding - can be performed by putting
rings at basis of varices.
Other Measures
(1) Balloon Temponade
The sangstaken- black more tube is passed
into the stomach and the balloon is
inflated and pulled back, which exerts
pressure on lower oesophages and
fundus to stop the bleeding.
Other Measures
(2) Le-Vein Shunt
A shunt is passed sub-cutaneously in
between the jugular vein and portal
vein.
Other Measures
(3) TIPS (Transjular Intrahepatic Portocaval Shunt)
• In this procedure a catheter is passed
from jugular vein to portal vein under
the u/s guidance.
Prophylais Agaist Re-Bleeding
Once the initial episode of bleeding is
controlled, the risk of rebleeding is 5080% without further therapy.
(1) Long term injection sclerotherapy
usually 4-6 treatment one required to
prevent rebleeding, but every year
endoscopy should be done to see the
condition of varices.
Prophylais Agaist Re-Bleeding
(2) B- Blockers (Non selective betablocker of propranolol)
It dilates the protal veins so decrease the
portal vein pressure. In case of
asthmatic patient glyceryl dinitrite can
be used.
Thanks