Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
•
94 likes•44,360 views
Hepatic Encephalopathy
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
Similar to Hepatic Encephalopathy -Pathophysiology,Evaluation And Management (20)
More from Santosh Narayankar
More from Santosh Narayankar (16)
Recently uploaded
Recently uploaded (20)
Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
- 1. Hepatic EncephalopathyHepatic Encephalopathy Dr.Santosh M Narayankar Department Of Gastroenterology Yashoda Hospital
- 2. Definition Hepatic encephalopathy is a brain dysfunction caused by liver insufficiency and/or PSS It manifests as a wide spectrum of neurological or psychiatric abnormalities ranging from subclinical alterations to coma. Reversible impairment of neuropsychiatric function.
- 3. Prevalence • Overall: 30%–40% of those with cirrhosis at some time during their clinical course. • The prevalence of OHE at the time of diagnosis of cirrhosis is 10%–14% in general. • In decompensated cirrhosis is 16–21%. • After TIPS: 10-50%. • CHE: 20-80%. • The risk for the first bout of OHE is 5%–25% within 5 years after cirrhosis diagnosis. • Recurrence: • 40% within 1st year after index OHE. • Recurrent OHE have a 40% cumulative risk of another recurrence within 6 months, despite lactulose treatment.
- 8. Pathogenesis • Ammonia Theory • SIRS • Manganese Theory • Genetics • Oxidative stress • Neurosteroids
- 13. SIRS
- 14. Systemic inflammatory response syndrome (SIRS) and Sepsis effect: • 1)Hyperammonemia induction by amino acid solution • deterioration of the psychometric test results. • 2)After SIRS treatment; • hyperammonemia induction by amino acid solution • No effect on the psychometric test results.
- 17. Manganese Theory
- 18. Genetics
- 19. Oxidative Stress
- 23. Prevalence -MHE
- 24. Natural History of CHE
- 38. Lumbar Puncture
- 40. Apple store Apps • Stoop Test • Inhibitory Control Test • Trail Marking Test • Line Drawing Test
- 42. Management
- 52. Enema
- 53. Nutrition
- 57. Antibiotics
- 58. Rifaximin
- 59. Ammonia Lowering Agents • LOLA • Sodium Benzoate • Sodium Phenylbutyryte • Glycerol phenylbuyryte • LOPA
- 60. LOLA
- 61. LOPA • Is similar to LOLA • OP (OCR-002) combines ornithine and PAA. • It supplies urea cycle with ornithine. • Phenylacetate + glutamine phenylacetylglutamine [easily excreted]
- 62. PEG
- 66. Embolisation
- 67. Post TIPS • Lactulose and Rifaximin are of no benefit in preventing post-TIPS HE. • The only effective therapy is to decrease the diameter of the stent.
- 68. Prophylaxis • There is no primary prophylaxis ???. • No drug was shown to prevent 1st HE episode after TIPS [Riggio et al., 2005]. • ??? Prevention of CHE to OHE.
- 69. Secondary Prophylaxis It is the prevention of second HE episode after index episode. • Lactulose can be used. • 46% recurrence of OHE due to lactulose misuse. • Combined lactulose and rifaximin have a decreasing risk of both breakthrough HE episodes as well as hospitalizations when compared with lactulose alone. • Probiotics [VSL#3] in a recent study is equal to lactulose [Agrawal et al., 2012].
- 70. When to stop secondary prophylaxis: • Usually it is used indefinitely. • Exception: • Controlled precipitating factor as variceal bleeding HE. • Improving liver condition as treated AIH, antiviral for HCV, HBV etc.
- 72. Artificial Liver Support Not studied well • In a small trial of 56 patients: • MARS with albumin infusion did not show faster recovery from HE. • Only a mortality benefit in albumin treated group. • May be used for refractory cases without survival benefit.
- 73. Liver Transplantation Liver transplantation resolves both hepatic dysfunction and portal hypertension • It usually results in complete resolution of HE. • Indication: recurrent or treatment resistant cases. • MELD obstacle: • HE does not necessarily correlate with MELD score. • Patients with HE may be disadvantaged in the era of MELD-based organ allocation despite a serious impact of HE on productivity, health, and survival.
- 74. Flumazenil • This drug is not frequently used. • It transiently improves mental status in OHE without improvement on recovery or survival. • The effect may be of importance in marginal situations to avoid assisted ventilation. • Likewise, the effect may be helpful in difficult differential diagnostic situations by confirming reversibility (e.g., when standard therapy unexpectedly fails or when benzodiazepine toxicity is suspected).
- 75. Treatment Of CHE