Hepatic Encephalopathy

Hepatic Encephalopathy is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

  • Hepatic encephalopathy is the syndrome of disordered consciousness and altered neuromuscular activity that is seen in patients with acute or chronic hepatocellular failure or portosystemic shunting.
  • Hepatic encephalopathy is classified according to the underlying disease into the following:
    • Type A: Resulting from acute liver failure
    • Type B: Resulting from portosystemic bypass or shunting
    • Type C: Resulting from cirrhosis.1
  • The grades of hepatic encephalopathy are dynamic and can rapidly change.
    • Grade I: Sleep reversal pattern, mild confusion, irritability, tremor, asterixis
    • Grade II: Lethargy, disorientation, inappropriate behavior, asterixis
    • Grade III: Somnolence, severe confusion, aggressive behavior, asterixis
    • Grade IV: Coma
  • Precipitating factors include medication noncompliance to lactulose, azotemia, FHF, opioids or sedative-hypnotic medications, acute GI bleeding, hypokalemia and alkalosis (diuretics and diarrhea), constipation, infection, high-protein diet, progressive hepatocellular dysfunction, and portosystemic shunts (surgical or TIPS).

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