Homer’s Hepatic Board Review: Hepatic Encephalopathy

• Intracranial hemorrhage (subdural hematomas are more common given the associated coagulopathy)
• Alcohol intoxication or withdrawal
• Sepsis
• Spontaneous bacterial peritonitis
• Anemia / GI bleed
• Nutritional encephalopathy (Wernicke-Korsakoff Syndrome)
• Uremia / Renal failure
• Hepatic encephalopathy

Asterixis. Sure, we all know to have Mr. Simpson hold out his arms extended at the wrists and notice his hands flap. To be really slick, you can have Homer stick out his tongue and you will notice it move back and forth when extended (doesn’t count if he is imagining a donut).

Trick question! Hepatic encephalopathy is a diagnosis of exclusion, and can often be caused by those other problems on your differential. It occurs from nitrogenous waste build up, which can be precipitated by:

• Large, protein-laden meals (Kansas City BBQ, anyone?)
• Occult GI bleed
• Transjugular intrahepatic portosystemic shunt (TIPS)
• Opioid or benzodiazepine accumulation (in the setting of impaired metabolism)

The symptoms of hepatic encephalopathy lie on a spectrum from fatigue to coma. The increased ammonia in blood can also contribute to cerebral edema and increased intracranial pressure, therefore exacerbating symptoms.

Patients will often have elevated serum ammonia levels, but the severity of encephalopathy and altered mental status does not reliably correlate with ammonia levels. It is imperative you consider the differential diagnoses in entirety and treat the inciting cause.

First: stabilization! These patients often require critical care and can decompensate quickly. Have a low threshold for intubation.

Treatment involves removal of nitrogenous waste and suppression of intestinal bacterial that produce this waste.

Lactulose is the main treatment and your board answer. It becomes lactic acid in the colon, making the colon acidic and trapping the ammonia for excretion. It can be given PO or PR. Why don’t we ask Mr. Simpson which he would prefer? Although lactulose has been the standard treatment for hepatic encephalopathy, the HELP trial suggests that polyethylene glycol may lead to more rapid hepatic encephalopathy resolution than standard therapy.[2]

You may assess severity and trend AMS changes with the West Haven Criteria, but ultimately use your clinical judgment.

• Grade I: Apathy, change in behavior without change consciousness
• Grade II: Lethargy, drowsiness, asterixis, disorientation
• Grade III: Marked confusion, incoherent speech, hyperreflexia
• Grade IV: Comatose, unresponsive to pain, decorticate or decerebrate posturing

Generally, Grade 1 and 2 may be able to go home in the absence of other co-morbidities and after consultation with the patient’s gastroenterologist.

Grades 3 and 4 should be admitted. Consider consultation with the ICU.

Bleeding Gums Murphy. He has scurvy! Or just bad gingivitis…. Get that man some oranges and a toothbrush.