Hepatic encephalopathy types

Lavoie J, Pomier Layrargues G, Butterworth RF Increased densities of peripheral-type benzodiazepine receptors in brain autopsy samples from cirrhotic patients with hepatic encephalopathy. Hepatology 1990 11 874-882. 

Hepatic encephalopathy is a neuropsychiatric syndrome which may complicate almost all types of liver disease. It may occur intermittently and be reversible or may occur acutely, with rapid progression to coma and death. Mrs MW presented with signs of hepatic encephalopathy including flapping tremor of the hands, intellectual deterioration, slurred speech, confusion, drowsiness and irritability. 

Drugs that can disturb fluid-electrolyte balance must be used with caution in patients with certain types of liver impairment. Diuretics, for example, are often required to treat ascites but can cause hypo-natraemia, hypo- or hyperkalaemia. A disturbance in electrolyte balance can lead to encephalopathy in susceptible patients such as cirrhotics or those with acute liver failure. Dehydration induced by diuretics is a common precipitant of hepatic encephalopathy. The mechanism is not fully understood, but could possibly be due to the reduced metabolism of hepatic toxins because of hepatic hypoxia [5]. 

Loguerdo C, Abbiati R, Rinaldi M, Romano A, Vecchio D, Blanco C, Coltorti M (1995) Longterm effects of Enterococcus faecium SF68 versus lactulose in the treatment of patients with cirrhosis and grade 1-2 hepatic encephalopathy. J Hepatol 23 39-46 Lopes MFS, Ribeiro T, Abrantes M, Marques JJF, Tenreiro R, Crespo MTB (2005) Antimicrobial resistance profiles of dairy and clinical isolates and type strains of enterococci. Int J Food Microbiol 103 191-198... 

Several strategies to treat alcoholic liver disease have been evaluated. Prednisolone may improve survival in patients with severe alcoholic hepatitis and hepatic encephalopathy. Nutrients such as S-adenosylmethionine and polyunsaturated lecithin have been found to have beneficial effects in nonhuman primates and are undergoing clinical trials. Other medications that have been tested include oxandrolone, propylthiouracil, and colchicine. At present, none of these drugs is approved for use in the U.S. for the treatment of alcoholic liver disease. The current primary treatment for liver failure is transplantation in conjunction with abstinence from ethanol. Long-term outcome studies suggest that patients who are alcohol-dependent have survival rates similar to those of patients with other types of liver disease. Alcoholics with hepatitis C may respond to interferon-2a (see Chapter 52). 

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. 

The two most serious complications of acute viral hepatitis found in J patients such as Percy Veere are massive hepatic necrosis leading to ful- minant liver failure and the eventual development of chronic hepatitis. Both complications are rare in acute viral hepatitis type A, however, suggesting that acetaminophen toxicity may have contributed to Percy s otherwise unexpectedly severe hepatocellular dysfunction and early hepatic encephalopathy. 

Als-Nielsen, B., L.L. Gluud, and C. Gluud, 2004. Non-absorbable disaccharides for hepatic encephalopathy Systematic review of randomised trials. Bmj, 328(7447) p. 1046 Azzopardi, J., et al.2002. Lack of evidence of cerebral oedema in adults treated for diabetic ketoacidosis with fluids of different tonicity. Diabetes Res CUn Pract, 57(2) pp. 87-92 Bachmann, C., 2002. Mechanisms of hyperammonemia. CUn Chem Lab Med, 40(7) pp. 653-662 Bhowmick, S.K., Levens, K.L. andRettig, K.R. 2005. Hyperosmolar hyperglycemic crisis An acute life-threatening event in children and adolescents with type 2 diabetes mellitus. Endocr Pract, 11(1) pp. 23-29... 

Hepatic Encephalopathy (HE) is a serious neuropsychiatric complication of both acute and chronic liver failure. A study group concluded in 2002 that HE is a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction after exclusion of other known brain diseases (Ferenci et al., 2002). A multiaxial definition of HE was proposed that defines both the type of hepatic abnormality and the characteristics of the neurological manifestations. Three types of hepatic abnormalities were defined, namely ... 

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome associated with severe, acute and chronic liver failure. According to the recommendations of a working party (Ferenci et al 2002) held at the d"" World Congress of Gastroenterology in Vienna in 1998, 3 types of HE should be differentiated, on principle ... 

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). 

This synthetic disaccharide, l, P-galactosido-fructose, b been in use abroad for a number of years as an effective cathartic. More recently it has found potential in the treatment of hepatic encephalopathy where it may have considerable advantage over other types of available therapy. 23,124 ijiie mechanism of action in these cases has been described as an "acid dialysis". Since lactulose is not metabolized by human disaccharidases and little is absorbed, 5 it passes to the colon where it is hydrolyzed by bacteria to lactic, acetic, and formic acids. The resultant decrease in the pH of the colonic contents has two effects the pH gradient stimulates passage of ammonia from the plasma to the intestinal lumen, and absorbable ammonia in the lumen is converted to nonabsorbable ammonium ions which are excreted.With the decreased ammonia content of the blood, patients have improved psychologically and behaviorally. 

Hypersensitivity Fever, skin eruptions of various types, including exfoliative dermatitis, infectious mononucleosis-like, or lymphoma-like syndrome, leukopenia, agranulocytosis, thrombocytopenia, Coombs positive hemolytic anemia, jaundice, hepatitis, pericarditis, hypoglycemia, optic neuritis, encephalopathy, Leoffler s syndrome, vasculitis, and a reduction in prothrombin. 

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. 

Diuretics are used widely for the treatment of hypertension see Chapter 32), and loop diuretics appear to lower blood pressure as effectively as Na+-CL symporter inhibitors e.g., thiazides and thiazide-hke diuretics) while causing smaller perturbations in the Upid profile. However, the short elimination half-lives of loop diuretics render them less useful for hypertension than thiazide-type diuretics. The edema of nephrotic syndrome often is refractory to other classes of diuretics, and loop diuretics often are the only drugs capable of reducing the massive edema associated with this disease. Loop diuretics also are employed in the treatment of edema and ascites of hepatic cirrhosis however, care must be taken not to induce encephalopathy or hepatorenal syndrome. In patients with a drug overdose, loop diuretics can be used to induce a forced diuresis to facilitate more rapid renal elimination of the offending drug. Loop diuretics, combined with isotonic saline administration to prevent volume depletion, are used to treat hypercalcemia. Loop diuretics interfere with the kidney s capacity to produce a concentrated urine. Consequently, loop diuretics combined with hypertonic saline are useful for the treatment of hfe-threatening hyponatremia. Loop diuretics also are used to treat edema associated with chronic renal insufficiency. Most patients with ARE receive... 

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