Hepatic encephalopathy

Today we discussed hepatic encephalopathy and its triggers. Some points that came up:

In the context of stable chronic liver disease, the triggers of hepatic encephalopathy are:
1) non-adherence to diuretics/lactulose/nadolol, etc.
2) psychoactive meds (narcotics, benzos)
3) volume overload (usu insufficient diuretics/NaCl excess)
4) new hepatic insult: hepatitis, HCC, PV thrombosis, Budd Chiari
5) infection: esp SBP
6) GI bleed/protein load
7) hypokalemia/alkalosis

Approach is to control encephalopathy and rule out/in precipitating causes:
1) All cirrhotics with ascites and worsening encephalopathy must be tapped. Also rule out other causes of infection
2) Lactulose 30cc BID, qid PRN for 2-3 loose BMs.
3) Diurese if needed, but consider holding if intravascularly depleted
4) D/C all meds that could contribute
5) Continue/start nadolol
6) Decide on ABx from clinical picture and preliminary tap cell count
7) Consider U/S with dopplers to r/o PV thrombosis, HCC, etc
8) If suspicion of GIB, possible OGD
9) Low salt diet. Fluid restrict.

Click here for the 2004 guidelines for cirrhosis managment from Hepatology

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