Hepatic Encephalopathy:

Type A: With Acute Hepatitis

Type B: With TIPS
Type C: With Cirrhosis
Staging + Child-pugh Scoring Why:
 To predict prognosis
 To treat & inform patient attendance
Staging:
Clinical Exam Rx
Stage 1 Sleep alteration Draw star Lactulose
Stage 2 Personality change Flapping tremor Lactulose
Drawing star
Stage 3 Restless Babinski positive  NG + IV
Clonus  Enema
 Rifaxamine
 ICU
Stage 4 Coma GCS< 8 ICU

Child Pugh Score: >9 = C (1 year survival 50%, 2 year 30%)

 Albumin> <28
 Bilirubin >50
 PT >6
 Encephalopathy
 Ascites
Another Scoring: MELD (INR, Creatinine, Bilirubin)
Why Scoring:
 Prognosis (Mortality & Survival)
 Liver transplantation
 MELD >14
 Child Pugh B, C
Stage 2: How detect bedside?
Patient attendance complains about
 Sleep alteration
 Personality change
 Constipation
Why Stage 3 / 4 important:
 Gag reflex lost. Respiratory arrest.
 Enema, Antibiotic & ICU is needed.
 Occurs due to Cerebral edema (Stage 4),
CT scan, EEG (Slow delta wave) confirms.

 Rifaxamine 550 mg (1+0+1) 70 tk for HE

 Rifaximine 200 mg (1+1+1) for Traveler’s Diarrhea/ IBS.
 Lactulose: 15 ml -30 ml (for 3-5 bowel movement daily)
 Lactulose= Lactitole
 Metronidazole is avoided for Neuropathy in long term use.

Pathogenesis in Neurology:
 The most important waste product is ammonia (NH3).
 This small molecule crosses BBB & absorbed by the astrocytes,
 Astrocytes use ammonia when synthesising glutamine from glutamate.
 The increased levels of glutamine lead to an increase in osmotic pressure in
the astrocytes, which become swollen.
 There is increased activity GABA
 Brain edema of the "cytotoxic" type