Acute Hepatic Encephalopathy 2/2 to ________
Symptoms caused by a failure of liver to detoxify NH3 and other substances that cause cerebral edema and/or act as false neurotransmitters (GABA-like)
Precipitating causes evaluated.
PE: Asterixis present?
Pt has hepatic encephalopathy stage____
Labs: Ammonia level, CMP (look for electrolyte abnormalities), CBC (look for signs of infection)
Studies: Consider CT head; KUB
Dx: asterixis can be seen; NH3 poor Se for dx & monitoring Rx; remains a clinical dx
DDx: Other causes of delirium.
Acute treatment:
Will Identify and correct any precipitating causes.
Will lower the blood ammonia concentration:
–Low protein diet (60–80 g/day),
–Lactulose (acidifies the colon and converts NH3 to NH4+ [ammonium ion]); the goal is 2–4 stools/day. May give lactulose enemas
–Rifaximin 400mg TID (decreases gut bacteria leading to decreased ammonia production). NB: Rifaximin and lactulose have similar efficacy. However, lactulose is the first line of treatment.
Secondary prevention: Lactulose daily +/- Rifaximin 550 bid