definition: Hepatic encephalopathy is brain and nervous system damage that occurs as a complication of liver disorders. It is characterized by various neurologic symptoms including changes in reflexes, changes in consciousness, and behavior changes that can range from mild to severe.

Grading of the symptoms of hepatic encephalopathy is as follows: Grade 0 - Clinically normal mental status but minimal changes in memory, concentration, intellectual function, and coordination Grade 1 - Mild confusion, euphoria, or depression; decreased attention; slowing of ability to perform mental tasks; irritability; and disordered sleep pattern, such as inverted sleep cycle Grade 2 - Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time Grade 3 - Somnolent but can be aroused, unable to perform mental tasks, disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech

Grade 4 - Coma with or without response to painful stimuli Patients with mild and moderate hepatic encephalopathy demonstrate decreased short-term memory and concentration upon mental status testing. They may show signs of asterixis, although the flapping tremor of the extremities is also observed in patients with uremia, pulmonary insufficiency, and barbiturate toxicity. Some patients show evidence of fetor hepaticus, a sweet musty aroma of the breath that is believed to be secondary to the exhalation of mercaptans. Other potential physical examination findings include hyperventilation and decreased body temperature.

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Si gn s a nd Sy mp toms : changes in mental state, consciousness, behavior, personality • forgetfulness • confusion, disorientation • delirium (acute, severe confusion with fluctuating level of consciousness) • dementia (loss of memory, intellect, reasoning, and other functions) • changes in mood • decreased alertness, daytime sleepiness • decreased responsiveness, progressive stupor • coma decreased self-care ability deterioration of handwriting or loss of other small hand movements coarse muscle tremors muscle stiffness or rigidity seizures (rare) speech impairment movement, uncontrollable movement, dysfunctional agitation

• Blood chemistry may show low albumin, high bilirubin, or other abnormalities. • Serum ammonia levels are commonly high. • Prothrombin time may be prolonged and not correctable with Vitamin K. • CT scan of the head may be normal, or may show general atrophy (loss of tissue). • EEG (electroencephalogram, a reading of electrical activity in the brain) shows characteristic abnormalities.


1. Reduce protein in the intestine. • recommend total elimination of dietary protein with an intake of fruit and intravenous fluids. • -protein may be restricted to 20-40 gm/day. • -assess or signs of gastrointestinal bleeding. Check for bright blood in the stool or for black tarry stools. Bleeding results in protein accumulation in the GIT, which exacerbates hepatic encephalopathy. 2. Reduce bacterial production of ammonia. • -neomycin and lactulose are useful pharmacologic agents for this purpose. Since neomycin is not absorbed into the circulation, it exerts a powerful effect in the intestinal bacteria responsible for ammonia production.

3. Eliminate fluid and electrolyte imbalance, hypoxia, infection, sedation • -maintain and monitor fluid balance to prevent further hepatic injury and reduced renal perfusion. • -deliver intravenous fluids evenly over a period of time. • -monitor vital signs and central venous pressure frequently. • -measure urine output hourly if necessary. • -be alert to possible harmful accumulation of ammonia due to diuretic therapy. Hypokalemia from the use of diuretics contributes to hepatic encephalopathy by increasing ammonia production in the kidney. 4. Maintain function in the unconscious person. • -turn the person frequently and promote lung aeration to prevent pneumonia and skin breakdown.

• • • • cerebral edema (brain swelling) Brain herniation progressive, irreversible coma permanent neurologic losses (movement, sensation, or mental state) • increased risk of:
• • • • sepsis respiratory failure cardiovascular collapse Kidney failure

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