Hepatic Encephalopathy (HE)
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Hepatic encephalopathy is a syndrome of neuropsychiatric symptoms and signs, including coma, observed in patients with cirrhosis. It is probably due to the accumulation of toxins in the blood.
Clinical features
- Grade 0: Subclinical – personality changes, construction apraxia (inability or difficulty to build, assemble, or draw objects)
- Grade I: Confusion, flap tremor
- Grade II: Drowsy
- Grade III: Stuporous
- Grade IV: Coma
- Encephalopathy may be aggravated by surgery, parencentsis, excessive diuretics, sedatives, and opioid analgesics
Management
- Management involves addressing the pathophysiological mechanisms related to brain, gut and liver
Treatment
- Identify and correct precipitating factors including renal impairment, gastrointestinal bleeding, infections, and electrolyte disturbances
- Empty the gut
- Give oral lactulose 15-30 mL every 8 hours until the condition resolves (aim at 2-3 soft stools/day)
- Lactulose can be administered through a nasogastric tube (grade 1 and 2) or as an enema in patients with acute HE (grade 3 and 4)
- Refer to a specialist
If referral delays
- Give an antibiotic with a local action on the gut: oral metronidazole 400–800 mg every 8 hours for 5 days
- Or oral paromomycin 1000 mg every 6 hours for 5 days