Encephalopathy asterixis

Markers of hepatic encephalopathy include decreased cognition, confusion, changes in behavior, and asterixis. 

In fulminant hepatitis with hepatic encephalopathy, patients may have asterixis and coma. 

Uremic and dialysis encephalopathies. Patients with renal failure continue to manifest neuropsychiatric symptoms despite significant advances in therapeutics and management. Patients with renal failure who are not yet on dialysis develop an array of symptoms, including clouding of consciousness, disturbed sleep patterns, tremor and asterixis that may progress to coma and death. 

Encephalopathy - Impaired cognition confusion obtundation altered mental status auditory/visual hallucinations psychosis (delirium, paranoia) mood changes (eg, mania, agitation, combativeness) diffuse hypotonus hyperreflexia myoclonus tremor asterixis involuntary movements major motor seizures lethargy/stupor/coma diffuse weakness. Approximately one-third of patients with a diagnosis of encephalopathy may have had... 

Cirrhosis is often asymptomatic until complications of liver disease are present. Mrs MW may present with itching, jaundice, dark urine, pale fatty stools, abdominal pain, nausea, fatigue, bleeding - such as nose bleeds, hepatic encephalopathy, hepatomegaly, ascites, distended abdominal veins, spider angiomata, palmar erythema and asterixis. She may also present with the signs and symptoms of alcohol withdrawal, which include irritability, anxiety, tachycardia, tremor, sweating, confusion and hallucinations. 

Asterixis, a jerky relaxation of tonically contracted postural muscles, was observed in some patients with structural lesions of the brain or metabolic encephalopathy who were taking levodopa, but not in patients with Parkinson s disease (10). 

The use of thiazide diuretics in hepatic cirrhosis is associated with a high incidence of severe hypokalemia, asterixis, and precipitation of encephalopathy (9). 

Percy Veere s symptoms and laboratory abnormalities did not slowly subside over the next 6 weeks as they usually do in uncomplicated viral hepatitis A infections. Instead, his serum total bilirubin, ALT, AST, and alkaline phosphatase levels increased further. His vomiting became intractable, and his friend noted jerking motions of his arms (asterixis), facial grimacing, restlessness, slowed mentation, and slight disorientation. He was admitted to the hospital with a diagnosis of hepatic failure with incipient hepatic encephalopathy (brain dysfunction caused by accumulation of various toxins in the blood), a rare complication of acute type A viral hepatitis alone. The possibility of a superimposed acute hepatic toxicity caused by the use of acetaminophen was considered. 

It must be emphasized that the combination of extra-pyramidal and cerebellar dysfunction is quite characteristic for hepatic encephalopathy, and cannot be found in any other kind of metabolic encephalopathy, except Wilson s disease. Asterixis, however, which is considered a classic sign of HE, is also seen in other metabohe or toxic encephalopathies, such as urania, CO retention, hypomagnesemia or intoxication with antiepileptic drugs, for example. 

Ammonia metabolism within the muscle may be improved by the administration of L-omithine-L- aspartate (LOLA). Controlled trials suggest that enteral and parenteral formulations of ornithine aspartate significantly reduce blood ammonia levels and have useful therapeutic effects in patients with cirrhosis and encephalopathy (Kircheis et al., 1997 Stauch et al., 1998). Poo et al. (2006) recently showed in a randomized, lactulose-controlled study of oral ornithine-aspartate in 20 patients with clinically overt HE that LOLA in contrast to lactulose significantly improved parameters of mental status, number connection test scores, asterixis scores and EEG. Both lactulose and LOLA reduced serum ammonia levels and improved quaUty of life scores. Since only 20 patients were included in this study the results cannot be considered proof for the superiority of LOLA compared to lactulose, while the data underscore the effect of both agents. Ornithine aspartate is well tolerated in general. From a theoretical point of view the combination of disaccharides and ornithine aspartate may be useful in patients with insufficient efficacy of only one of the two drugs. 

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