Hepatology

case presentation

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Under the supervision of

Prof.Dr. Sahar Hegazy

Professor of clinical pharmacy department ,Tanta University

Dr. Noura EL-Saka

PharmD Preceptor

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 ● Mohamed Heidar Rashad
● Safaa Mahmoud Algonaimy
● Nehal Mahmoud Elnagar
● Faten Basem Abohamar
Presented by ● Noha Abdrabu Hasan
● Samah Magdy Saad
● Hajar Hossam Eldin Saad
● Mohamed Osama Zaki
● Omar Salah Mohammed

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 ● Hepatic Encephalopathy
● Case Presentation
Content ●
●
Problem list
Steps ( 1 - 10)

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 Hepatic Encephalopathy

Hepatic Encephalopathy is a decline in brain functions that occurs as a Complication of Liver

Failure

Hepatic Encephalopathy Happens because liver is unable to remove toxins (e.g., Ammonia) from
Blood

Transported
via portal vein
Nitrogen
Urea
Compounds

Excreted By Excreted
Kidney

Gut Bacteria

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 Hepatic Encephalopathy

Nitrogen Compounds
Ammonia (Cross Blood-
• Mood Changes
Brain-Barrier) • Confusion
Systemic
Circulation • Comma

Transported via
portal vein

Nitrogen
Urea
Compounds

Shunt
Portal Vein Excreted

Gut Bacteria

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 Hepatic Encephalopathy
CAUSES

Directly In Chronic Liver Failure

Due to Liver Failure
Triggering Factors

Common in Acute Liver • Excessive Nitrogen Load

Failure o Kidney Injury
o GI Bleeding (Esophageal Varices)
o High Protein Intake

• Metabolic Disturbances
o Hyponatremia, Hypokalemia (Excessive Diuresis)

• Drugs
o Benzodiazepines,Antipsychotics
• Infection
Spontaneous Bacterial peritonitis 7
Hepatic Encephalopathy
GRADING
(West haven criteria)
• GRADE 0 (Minimal)
o Mild decrease in intellectual ability & coordination
o Inverted Sleep-Wake Cycle

• GRADE 1
o Lack of awareness, Anxiety, Shortened attention span

• GRADE 2
o Lethargy, Personality changes, Inappropriate behavior,
Minimal space, time disorientation

• GRADE 3
o Stuporous but respond to verbal stimuli, Gross Disorientation

• GRADE 4
o Coma 8
 Hepatic Encephalopathy
OTHER CLINICAL FEATURES

• Asterixis
o A Flapping tremor of the hand that appears when the rest is
extended

• Clonus
• Seizures
• Musty Smell (Fetor Hepaticus)

• Manifestations of underlying liver disease

o Cirrhosis
o Jaundice
o Caput Medusa

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 Hepatic Encephalopathy
DIAGNOSIS

Hepatic Encephalopathy only diagnosed in the presence of hepatic disease

• Type A
o Hepatic Encephalopathy associated to Acute Liver Failure

• Type B
o Hepatic Encephalopathy associated to Portal-Systemic Shunting

• Type C
o Hepatic Encephalopathy associated to Cirrhosis
o Episodic
o Persistent
o Minimal

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 Treatment
1- Nutritional support
2- correction of precipitating
causes
3- Lowering blood anemia

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1- Nutritional support

● Maintaining energy intake of 35 to 40 kcal/kg/day.

● Protein intake of 1.2 to 1.5 g/kg/day ,as Patients with cirrhosis are often malnourished .

● If symptoms worsen with protein intake, substitute to fish ,milk ,or meat with vegetable proteins may
improve nitrogen balance and mental status.

● BCAA supplementation is indicated only in severely protein-intolerant patients.

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2-Correction of precipitating causes

● Identification and correction of causes as Gastrointestinal bleeding, Infection, Constipation, Renal

failure, Hypoxia ,Sedative use and hypokalemia.

● Treatment combined with standard therapy is typically associated with a prompt improvement in
mental status and hepatic encephalopathy

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 3-Lowering blood ammonia

a- Lactulose

● Nondigestible synthetic disaccharide laxative hydrolyzed in gut to an osmotically active compound

● Drawing water into colon and stimulates defecation.
● Lowering colonic pH, so ammonia (NH3) converts to ammonium (NH4+) that cannot cross back from
gut into systemic circulation as it is ionic

Initiate at 15 to 30 mL two to three times per day and titrate to a therapeutic goal of two to three soft bowel
movements daily.

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3-Lowering blood ammonia

b- Rifaximin

For patients without improvement in mental status within 48 hours or who cannot take lactulose

non absorbable antibiotic that decreases urease-producing gut bacteria, decreasing ammonia production

400 mg orally three times daily or 550 mg orally two times daily

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3-Lowering blood ammonia

C- Neomycin
● associated with ototoxicity and nephrotoxicity ,so for patients who are unable to take rifaximin
● Various doses have been used, generally use 1 gram twice daily or 500 mg three times a day.

● Other antibiotics that can be used include metronidazole

D-L-ornithine-L-aspartate

● Lowers plasma ammonia concentrations by enhancing the metabolism of ammonia to glutamine.

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Treatment of Hepatic encephalopathy

1-Patients with mild hepatic encephalopathy 2-Patients with severe cases (grades III to IV)
(grade I) may be managed as outpatients, if require hospital admission for treatment.
worsening bring the patient to hospital if
needed.

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 Patients with recurrent encephalopathy

Suggest continual administration of lactulose ,

The dose of lactulose 30 to 45 mL [20 to 30 grams] orally two to four times per day and titrated to achieve .
.two to three soft stools per day
If needed (eg, if hepatic encephalopathy is not adequately treated or recurs despite lactulose , Rifaximin can
be added to the regimen

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 Name: H.I

Age: 57

Gender: male

Weight: 89 kg

case scenario Height: 175 cm

Date of admission: 21/12/2022

BMI: 29.06

ABW: 77.88

IBW: 70.46

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Medication
History
Unknown

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Past medical
history ● Liver Cirrhosis
● HCV +ve
● Varicectomy

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On admission
● H.E grade 2
complain ●
●
L.L swelling
Ascites
● confusion
● Abdominal enlargement
● Slurred speech
● cough with sputum
● Inflammation scrotal edema

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Investigations ● Bilateral vesicular breathing with
inspiratory consonating crepitation
● Not cardiac
● Not renal
● X_Ray Done on chest

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Lab investigations

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 Normal 22 /12 23 /12 24 /12
Test / Date 21 /12
range

Hb 14-18 gm/dl 7.7 7.5 8.2

WBCS 5.2

RBCS 2.1

PLT 150 - 450 40

INR 1 2.57 2.5

PT 31.7 30

Alb. 3.5 - 5.5 2.5 2.5

AST 5 - 40 32

ALT 5 - 40 21
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Test / Date Normal range 21 /12 22 /12 23 /12 25 /12

Na 135 - 145 134 130 129

K 3.5 - 5.2 3.3 3.78 3.8

Bil.T 0.3 - 1 7

Bil.D 0.1 - 0.3 3

S.urea 119 114 125 140

S.Cr 0.7 - 1.3 1.8 1.7 1.5 1.1

CRP 24

Cr.Cl 90 - 140 38 40.2 45.6 62.2

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 ABG
PH 7.41

Co2 35.9

HCO3 22.7

21/12 22/12 23/12 24/12 25/12

BP 100/70 110/70 100/70 120/80 110/70

HR 70 90 98 88 90

Temp 37 37 37 37

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Ascitic fluid examination
21 / 12 23 /12

Colour reddish yellow orange

Aspect semi turbid semi turbid

Protein 1.3 2.1

Glucose 119 mg/dl 93 mg/dl

Neutrophil 60 % 85 %

Lymphocyte 40 % 15 %

Total leucocytes 500 cell 350 cell

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 4
GENEVA Score

IMPROVE Bleeding Score 10

Child-Paug Class
C

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 DVT Mechanical Prophylaxis

Prophylaxis Patient is at risk of DVT , with high

bleeding risk

Stress ulcer Indicated

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Drug List

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 Drug Dose Frequency Route T1 T2
Hepa - merz 40 mg OD injection 22/12

Ursofalk 500 mg BID oral 22/12

Esomeprazole 40 mg OD IV 22/12

Alphintern TID oral 22/12

Torsemide 20 mg OD oral 25/12

Calcium 665 OD oral 25/12

Albumin BID IV 25/12

Rifaximin 400 mg TID oral 22/12

Lactulose syp 15 ml TID oral 21/12

Lactulose enema TID enema 21/12

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 Drug Dose Frequency Route T1 T2
spironolactone 200 mg OD oral 25/12

Aminolepan OD IV 22/12 24/12

KCl+500 ringer OD infusion 22/12

Sultamicillin 1.5g 12 hr IV 22/12 25/12

Levofloxacin 500 mg 24 hr IV 24/12

Ceftriaxone 2g 24 hr IV 22/12 week

Fusi cream TID Topical 23/12

Hemoclar cream TID Topical 23/12

Normal Saline 500 ml OD IV 21/12

Lead acetate 12 hr 23/12

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 ● Cirrhosis
● Ascites

Problem List ●
●
Encephalopathy grade II
SBP
● Hypoalbuminemia
● Pneumonia
● Cough
● Yellowish Sputum
● crepitation
● Inflamed Scrotal Edema
● Anemia

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 Anemia
Indication without The patient is anemic need to
medication determine source of anemia (lab test
t.sat, ferritin), Spleen Examination,
Bone marrow aspiration)

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 Sultamicillin

Medication Patient started ceftriaxone so no need

to continue on it
without indication Ursofalk
No bile duct obstruction indicated so
no need for it

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 Drug
Contraindications
No drug contraindications

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 • Levofloxacin Appropriate dose (CrCl
30-50) is 750 mg / 48 hr
Dose oral lactulose: 20-30 g (30-45 ml) 2 to

Adjustment
4 times to achieve 2-3soft stools/day
Enema:200g (300ml)in 700ml NS or
water for 30-60 min every 4-8 hr

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 C Spironolactone (Antihypertensive Agents) –
Torsemide (Loop Diuretics) enhance the
hypotensive effect of Antihypertensive Agents

Drug - Drug D Potassium Chloride (Potassium Salts) –

Spironolactone (Potassium-Sparing Diuretics) •

Interactions
Potassium Salts enhance the hyperkalemic
effect of Potassium Sparing Diuretics

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Administration
Issues No administration issue needed

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 1-Sulbin 1.5mg: hepatotoxic
2-Lactulose: electrolyte imbalance
3-Ceftriaxone 1gm:renal / hepatic
impairment
Warning & 4-Calmag tab:electrolyte abnormalities

Precautions 5-Aldactone: fluid/electrolyte

imbalance
6-Hepa-Merz severe renal insufficiency

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 1-Aldactone (spironolactone)
Serum k -Serum electrolytes
2-Hepamerz amp:Serum ammonia
3-Lactulose: Fluid status
-Bowel movement-Serum electrolytes
Monitoring 4-Cal-mag:Serum ca .mg .phosphate
5- Monitor blood pressure

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Recommendatio Torsemide-Aldactone:
ns dose should be titrated

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References

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any questions

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thanks

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