Hepatic encephalopathy grading

Flumazenil has been used as a non-specific treatment in patients with hepatic encephalopathy [88, 89. However, it was effective in only some subjects in a double-blind, placebo-con-trolled, crossover study in 527patients with cirrhosis and hepatic encephalopathy grade III and IVa, of whom 265 received flumazenil and 262 received placebo [90 ]. There was improvement of the neurological score in 18% of the patients with grade III encephalopathy and in 15% of those with grade IVa compared with 3.8% and 2.7% respectively of those who received placebo electroencephalography improved in 28% and 22% compared with... 

Francavilla R, Barbarini G. Flumazenil for hepatic encephalopathy grade III and IVa in patients with cirrhosis an Italian multicenter double-blind, placebo-controlled, cross-over study. Hepatology 1998 28(2) 374-8. 

Six unselected patients (four women), mean age 27 years, with acute liver failure and grade IV hepatic encephalopathy received terlipressin 0.005 mg/kg as a single intravenous bolus (16). There was an increase in cerebral blood flow 1 hour after the bolus, which returned to baseline at 5 hours, and an increase in intracranial pressure at 1 hour, which returned to baseline at 2 hours. The authors speculated that terlipressin could have a deleterious effect on cerebral hemodynamics in patients with severe hepatic encephalopathy. 

A 17-year-old man developed toxic subacute hepatitis with grade II encephalopathy and coagulation disorders a few days after consuming ecstasy. Liver transplantation was performed and he recovered fully. 

Kircheis, G., Wettstein, M., Timmermann, L., Schnitzler, A., Haussinger, D. Critical flicker frequency for quantification of low-grade hepatic encephalopathy. Hepatology 2002 35 357—366... 

Loguercio, C., Abbiati, R., Rinaldi, M., Romano, A., Dei VeccMo Bianco, C., Coitori, M. Long-term effects of Enterococcus faecium SF 68 versus lactulose in the treatment of patients with cirrhosis and grade 1-2 hepatic encephalopathy. X Hepatol. 1995 23 39-46... 

A 6-year-old boy sustained pelvic injuries and a femoral fracture. The first anesthetic he received consisted of thiopental, suxamethonium, isoflurane, and nitrous oxide. He also received two units of blood. He subsequently underwent four halothane anesthetics over 6 weeks for dilatation of a urethral stricture. Two days after the last anesthetic he was noted to be jaundiced. He had a negative viral screen but was positive for antitrifluoroacetyl IgG antibodies. He developed fulminant hepatic failure with grade 2 hepatic encephalopathy and underwent an auxiliary Uver transplantation 24 days after his last exposure to halothane. He died of septicemia 18 days later. Both at autopsy and on a previous hepatobiliary scan he was noted to have had extensive native Uver regeneration. 

Charcoal hemoperfusion can also remove the toxin in hepatic failure. A model of galactosamine-induced fulminant hepatic failure in a rat with grade 3 hepatic encephalopathy, demonstrated the potential utility of multisorbent plasma perfusion over uncoated spherical charcoal, and an endotoxin removing adsorbent (polymyxin B-sepharose). Timing, duration and frequency of treatment impacted liver cell proliferative response as compared to untreated fulminant hepatic failure paired controls (Ryan et al., 2001). 

Ong, J.P., et al., et al.2003. Correlation between ammonia levels and the severity of hepatic encephalopathy. Am J Med, 114(3) pp. 188-193 Puliyel, J.M. and V. Bhambhani, 2003. Ketoacid levels may alter osmotonicity in diabetic ketoacidosis and precipitate cerebral edema. Arch Dis Child, 88(4) p. 366 Roberts, J.S., et al.2006. Cerebral hyperemia and impaired cerebral autoregulation associated with diabetic ketoacidosis in critically ill children. Crit Care Med, 34(8) pp. 2217-2223 Ryan, C.J., et al.2001. Multisorbent plasma perfusion in fulminant hepatic failure effects of duration and frequency of treatment in rats with grade 111 hepatic coma. Artif Organs, 25(2) pp. 109-118... 

Unfortunately, the development of brain edema can hardly be monitored in patients with acute liver failure. Brain edema mostly occurs when hepatic encephalopathy has progressed to grades III to IV. In grades I-II encephalopathy, it has rarely been observed. With progression to grade III HE cerebral edema occurs in up to 35% and with grade IV HE in 65 to 75% of the patients (Munoz, 1993). 

As in acute liver failure, the main symptoms of HE are alterations in consciousness, cognitive dysfunction and motor disturbances. While patients with ALE often appear irritable and restless in the very beginning, psychomotor slowing is characteristic for type C HE. The alteration of consciousness is the basis for the 4-stage grading system of hepatic encephalopathy used world wide (West Haven classification) (Atterbury et al., 1978). 

A 33-year-old chronic alcoholic with hepatitis C developed acute liver and renal insufficiency with grade III encephalopathy. Hemodialysis was begun and emergency liver transplantation was performed. The explanted liver showed marked diffuse macrovesicular steatosis with massive coagulative-type necrosis. The postoperative course included a persistently raised gamma-glutamyltransferase, but he recovered fully after 60 days. 

A 16-year-old woman consumed ecstasy and developed jaundice, hepatic failure, a prothrombin ratio of 9, and grade I encephalopathy. She had a liver transplant and was asymptomatic at 11 months. 

Hepatic Ammonia reduction (lactulose. Grade of encephalopathy, EEC, Maintain functional capacity, prevent... 

Mans AM, De Joseph MR, Hawkins RA. Metabolic abnormalities and grade of encephalopathy in acute hepatic failure. J. Neurochem., 63, 1829-1838, 1994 McEnery MW, Snowman AM, Trifiletti RR, Snyder SH. Isolation of the mitochondrieil benzodiazepine receptor Association with the voltage-dependent anion channel tuid the adenine nucleotide carrier. Proc. Natl. Acad. Sci. USA, 89, 3170-3174, 1992 Mena EE, Cotman CW. Pathologic concentrations of ammonium ions block 1-gluttunate uptake. Exp. Neurol, 59, 259-263, 1985... 

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