20 hepatic enchephalopathy
DESCRIPTION
TRANSCRIPT
HEPATIC ENCEPHALOPATHY
GAO XIANGDepartment of Gastroenterology
The First Affiliated Hospital
DEFINITION
Hepatic encephalopathy is a reversible neuro-psychiatric state that complicates severe liver disease(HE).
AETIOLOGY
Encephalopathy associated with Cirrhosis and portal hypertension
Encephalopathy associated with portal-systemic Bypass without hepatocellular disease
Encephalopathy associated with Acute liver failure
Concensus in Hepatic Encephalopathy, WCOG, 2001; in press
Hepatic encephalopathy-A complication of cirrhosis of the liver
0 20 40 60 80 100 120 140 1600
20
40
60
80
100Pr
obab
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of c
ompl
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ions
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Gines et al. Hepatology (1987) 7, 1:122-128
Months
Key questions Mechanism: clearance of toxins central system --- treatment
Clinical manifestation: neuro-psychiatric changes --- diagnosis and clinical grading
PATHOGENETIC MECHANISM
Ammonia toxicity theory False neurotransmitters theory & amino acid imbalance theory Gama-aminobutyric aicd and endogenou
s benzodiazepines (GABA/BZ ) receptor complex theory
Others
intestinal Precipitating factors bacteria/protein GI bleeding
infection
liver removed hypokalemia and/or alkalosis
portal-systemic shunt hypovolemia and/or hypoxia
large protein meal
blood-brain barrier constipation drugs(sedatives )
cerebral toxicity hypoglycemia
Ammonia intoxication theoryNH3 NH4
urea&
H+
Branched-chain amino acid /Aromatic amino acids 3-3.5 :1 (normal)
<1 : 1 (cirrhosis)------ the use of branched-chain amino acid
Amino acid metabolic imbalance
Tyrosine intestinal bacterial decarboxylase
L-dopa Tyrosine Phenylalanine
Dopamine (Liver)
Noradrenaline Octopamine -phenylethanolamine true false Sympathetic transmitter
Brain function disturbed
False neurotransmitterColon: protein
x(Brain)
GABA/BZ receptor complex theory
•GABA (from intestine produced by bacteria)
•Endogenous BZ
--- the use of benzodiazepine antagonist
CLINICAL MANIFESTATION
DIAGNOSIS AND
DIFFERENTIAL DIAGNOSIS
• Severe liver disease or portal-systemic shunt
• Neuropsychiatric manifestation• Precipitants that induce HE• Obvious impaired liver function tests, eleva
ted blood ammonia level, flapping tremor and typical EEG change indicate the possible diagnosis
Diagnosis
Coma induced by other causes
Differential diagnosis
TREATMENT
1. Identification & correction of the precipitating cause: Precipitating factors Drugs! Electrolyte imbalance – hypokalemia/metabolic alkalosis (diuretics, vomiting, diarrhea, infusion) GI Bleeding Infection Constipation Large protein meal …….
2. Intervention to reduce the production & absorption of gut-derived ammonia & other toxins:
1) Diet: reduce and modify dietary protein and maintain Calorie intake
2) Enemas (mild acid) and/or purgation3) Lactulose or lactitol4) Inhibition of gut bacteria: Antibiotics: neomycin(oral), metronidazone?5) Modification of colonic flora: probiotics?
Modify colonic flora, resulting in displacement of urease-containing bacteria with lactobacillus
Cathartic effect
Lower the colonic pH, resulting in the formation of nonabsorbable NH4 from NH3 in the colon
3. Stimulation of metabolic ammonia metabolism: 1) Ornithine-aspartate: enhancing the metabolism
of ammonia to glutamine 2) Sodium glutamate or potassium glutamate,
Arginine? 3) Sodium benzoate(oral): acting with glycine in
the colon to form hippurate which can be excreted in the urine
- applied in chronic HE, particularly in those with elevated blood ammonia
4. Correct amino acid metabolic imbalance: infusion or oral administration of BCAA (branched-chain amino acid)
5. GABA/BZ complex antagonist: flumazenil ( particularly if patient has been given
banzodiazepines )
6. Other drugs
7. Miscellaneous treatment
Prevention and treatment of cerebral edema
8. Temporary hepatic support
9. Liver transplantation
PROGNOSIS
Acute hepatic failure (+++) Cirrhosis - with precipitant (++) Cirrhosis - portal-systemic shunt (+) Cirrhosis - end stage (++++)