HEPATIC ENCEPHALOPATHY

Chanak Trikhatri Medical Surgical

Introduction Hepatic encephalopathy is a neuropsychiatric

syndrome caused by liver disease. It is a life threatening complication of liver disease , occurs with profound liver failure and may result from the accumulation of ammonia and other toxic metabolites in the blood.

As it progresses, confusion is followed by coma.

Epidemiology

Approximately35% of all patients with cirrhosis of the liver die in hepatic coma

Etiology

Decrease in hepatocellular function Hypoxia Infection Diuretics (produce hypokalemia,

alkalosis and hypovolemia) Depressants :- phenobarbital,

narcotics, tranquilizers and sedatives Gastrointestinal bleeding

Contd..

Medications containing ammonium or amino compounds

Increased protein intake Constipation Dehydration

Pathophysiology

The specific cause of hepatic encephalopathy is unknown but characterized by elevation of ammonia level in the blood and cerebrospinal fluid.

Ammonia is produced in GI tract when protein is broken down by bacteria, by liver and in lesser amount by gastric juices and peripheral tissue metabolism.

Clinical Manifestation

Change of intellect, personality, emotion and consciousness with or without neurological sign.

The degree of encephalopathy can be graded from 1 to 4.

Grade :- 1 Poor concentration, slurred speech,

disordered sleep rhythm

Contd… Grade :- 2 Drowsy but easily rousable, occasional

aggressive behavior, lethargic Grade :-3 Marked confusion, drowsy, sleepy but

responds to pain and voice, gross disorientation

Grade :-4 Unresponsive to voice , may or may not

respond to painful stimuli, unconscious.

Contd…

Earliest feature are very mild and easily overlooked but as the condition becomes more severe , apathy, inability to concentrate, confusion, disorientation, drowsiness, slurring of speech and eventually coma develop.

Convulsion sometimes occur.

Stage of Hepatic Encephalopathy stage :- 1 Fatigue Restlessness Irritability Decreased intellectual performance Decreased attention span Diminished short term memory Personality change Sleep pattern reversal

Stage of Hepatic Encephalopathy contd… Stage :- 2 Deterioration in handwriting Asterixis (flapping tremor jerky movement of hand

specially present in HE) Drowsiness Confusion Lethargy Pruritus Fetor hepaticus (musty odour due to presence of

circulating methionine )

Stage :- 3 Severe confusion Inability to follow commands Deep somnolence, but rousable Stage :- 4 Coma Unresponsive to painful stimuli Possible decorticate or decerebrate

posturing

Stage of Hepatic Encephalopathy contd…

Diagnostic Evaluation History collection Physical examination:- flapping tremor inability to perform simple mental arithmetic task

or draw object such as star, Arterial amonia is usually increased As condition progress hyper- reflexia, bilateral

extensor plantar responses. Sweet and fruity smell from breath EEG:-show generalized slowing , an increase in

amplitude of brain waves and characteristic

Management

The principles of management for HE are to treat or remove the causative factor and to suppress the production of neurotoxins by bacteria in the bowel.

Medical management

Lactulose (15-30 ml 8 hourly) is a disaccharide which is taken orally and reaches the colon intact, to be metabolised by colonic bacteria.

The dose is increase slowly until bowel is moving twice daily.

It produces an osmotic laxative effect , reduces pH of the colonic content, thereby limiting colonic ammonia absorption and promotes the incorporation of nitrogen into bacteria.

Contd…

Neomycin (1-4 g 4-6 hourly) is an antibiotic which acts by reducing the bacterial content of the bowel. It can be used in addition or as alternative to lactulose intolerance

Dietary protein restriction is rarely needed and is no longer recommended as first line treatment because it is unpalatable and can lead to worsening nutritional state in already malnourish patient.

Surgical management

Liver transplantation surgery is indicated for chronic or refractory hepatic encephalopathy

Nursing Management

History taking Physical Examination Assess for changes of intellect, personality,

emotions and consciousness Assess for severe apathy, inability to

concentrate, confusion and disorientation drowsiness, slurring of speech and coma

Bilateral extensor planter response Paraplegia dementia Assess the result of ABG, electrolyte level

Nursing Diagnosis

Deficient fluid volume related to bleeding, decreased intake and ascites as evidence by physical examination

Ineffective breathing pattern related to hypoxia

Imbalanced nutrition less than body requirement related to GI adverse effect

Risk for injury related to loss of protective mechanism secondary to hepatic coma

Activity intolerance Self-care deficit Disturbed sleep pattern Impaired verbal communication Risk for aspiration Impaired gas exchange Impaired tissue integrity Disturbed sensory perception

Other Nursing Diagnosis

Interventions Fluid balance must be balanced hence should

start Intravenous therapy Maintained and monitor to prevent further

hepatic injury and reduced renal perfusion Monitor vital sign frequently Measure urine output hourly Monitor electrolyte and acid base balance

because its disturbances such as hypokalemia and alkalosis may precipitate hepatic encephalopathy

Contd… Hepatic coma may create a multitude of

problem for the client with encephalopathy. Prevent hypoxemia (to prevent and treat

hypoxemia ,attend to respiratory intervention like maintain airway.

Prevent nosocomial infection Prevent ammonia toxicity and hypokalemia Prevention to the injuries

Reference

Boon, N.A., Colledge, N.R., Walker, B.R. (2008). Davidson’s Principles and Practices of Medicine (20th Ed). Churchill Livingstone Elsevier.

Nettina, S.M. (2014). Lippincott Mannual of Nursing Practice (10th Ed). Wolter Kluwer:India