Hepatic Encephalopathy By Charis Conradi

Overview Name Epidemiology Classification Treatment Future Sources

What is HE Heaptic= Liver Encephalo = brain -pathy = disorder  „spectrum of neuropsychiatric abnormalities in patients with liver dysfunction” Blood test – ammonia concentration characterized by personality changes, intellectual impairment, and a depressed level of consciousness Normal ammonia level : The lower limit of the reference range is 10-20 μmol/L. The upper limit of the reference range is 35-65 μmol/L

Epiology accumulation in the bloodstream of toxic substances Excessive nitrogen load Drugs and medications Excessive alcohol consumption Infections portosystemic shunt surgery Unknown 20-30%

Liver functions Protein metabolsim Carbohydrate metabolism Fat metabolsim Bile production Vitamin storage Fibrinogen, prothrombin, factor VII (vitamin K dependent) Excrition of Hormones and Drugs Protein metabolism : Deamination of amino acids, UREA formation Plasma protein formation ( 90%) Carobohydrate metabolism: Glycogen storage Conversion of galactose and fructose to glucose Gluconeogenesis Fat metabolism : Synthesis of cholesterol, lipoproteins Vitamin Storage : A retina : combines with protein opsin to form rhodopsin = rod photoreceptors thus function in case of less light situations ; D : needed for calcium and phosphate regulation, enhances mineralization of bone; B12 Hormons: steroid hormons – estrogen, cortisol, aldosterone

Epidemology total deaths worldwide from cirrhosis and liver cancer rose by 50 million per year over 2 decades, according to the first-ever World Health Organization (WHO) study of liver disease mortality.4 Alcohol-attributable liver cirrhosis deaths per 100,000 people in 2010 by global-burden-of-disease region

Causes Liver failure observed in nearly 70% of patients with cirrhosis acute  onset between 7 and 28 days chronic observed in nearly 70% of patients with cirrhosis 24-53% of patients who undergo portosystemic shunt surgery Liver failure : liver become damaged beyond repair and the liver is no longer able to function, occurs gradually and over many years Hepatitis B Hepatitis C Long-term alcohol consumption Acute :rapid development of hepatocellular dysfunction

from liver failure to brain damage Nitrogen compounds  portal vein urea cycle  excreted by kidney impaired due to damaged hepatocytes or due to portosystemic shunts (venous blood bypasses the liver)  Nitrogenous waste products accumulate in the systemic circulation ammonia (NH3)  blood brain barrier organic compounds containing amine (-NH2) and carboxylic acid (-COOH) functional groups, usually along with a side-chain specific to each amino acid.[1][2][3] The key elements of an amino acid are carbon, hydrogen, oxygen, and nitrogen small molecule crosses the blood–brain barrier and is absorbed and metabolised by the astrocytes, a population of cells in the brain that constitutes 30% of the cerebral cortex. Astrocytes use ammonia when synthesising glutamine from glutamate.

NH3 Astrocytes : glutamine glutamate Increased amount of glutamine Increased osmotic pressure  brain edema small molecule crosses the blood–brain barrier and is absorbed and metabolised by the astrocytes, a population of cells in the brain that constitutes 30% of the cerebral cortex. Astrocytes use ammonia when synthesising glutamine from glutamate. The increased levels of glutamine lead to an increase in osmotic pressure in the astrocytes, which become swollen. There is increased activity of the inhibitory γ-aminobutyric acid (GABA) system, and the energy supply to other brain cells is decreased. This can be thought of as an example of brain oedema of the "cytotoxic" type.[10]

Stages - West Haven Criteria Grades State of consciousnes Intellectual function Personality behavior Neuromuscular disorders 1 Trivial lack of awareness Sleep disorder Shortened attention span  Euphoria or depression Asterixis tremor 2 Lethargy „forgefulness“ Disorientation to time Amnesia of recent events Inappropriate behavior  Anxiety -Slurred speech  -Hyperactive reflexes 3 Somnolence ( sleepiness) to stupor Confusion  Gross disorientation Bizarre behavior Babinski relfex, rigidity 4 Coma (unresponsive to verbal/noxious stimuli) Unable to test Asterixis : flapping tremor (patient in front of you, wrist extended! Physician further extends patiends hands which leads to a uncontrolled flapping tremor!!! Either symmetric or asymmetric Stupor is the lack of critical cognitive function and a level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain. Babinski reflex is one of the normal reflexes in infants. Reflexes are responses that occur when the body receives a certain stimulus. The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.

Treatment Type 1 due to acute liver failure Type 2 (bypass) Intubation Transplantation Type 2 (bypass) Occlusion of bypass Type 3 (infections) Antibiotics

Perspective Multiple causes Vaccination Less alcohole consumption

Sources http://www.nature.com/ajg/journal/v104/n6/fig_tab/ajg2009160t1.html criteria http://emedicine.medscape.com/article/2054408-overview normal Nh3 levels Gython and Hall Textbook of physiology http://emedicine.medscape.com/article/186101-overview Medscape : Hepatic Encephalopathy  http://www.medscape.com/viewarticle/813788 Medscape : Global Burden of Liver Disease Substantial http://pubs.niaaa.nih.gov/publications/arcr352/174-183.htm

https://www. google. com/search https://www.google.com/search?q=Babinski+sign&biw=1525&bih=702&tbm=isch&imgil=KbbJ6hhgVj-vAM%253A%253BU5CbBkWDtQQ5EM%253Bhttp%25253A%25252F%25252Fmedchrome.com%25252Fbasic-science%25252Fanatomy%25252Flesions-of-upper-motor-neurons-and-lower-motor-neurons%25252F&source=iu&pf=m&fir=KbbJ6hhgVj-vAM%253A%252CU5CbBkWDtQQ5EM%252C_&dpr=0.9&usg=__QdwYOGPcu6v24fh4E2-uCHSCvo0%3D&ved=0CEAQyjdqFQoTCKueqc7vycgCFYxxFAodDHkEEg&ei=BXAiVuuHCIzjUYzykZAB#imgrc=nC7vHK11teZqoM%3A&usg=__QdwYOGPcu6v24fh4E2-uCHSCvo0%3D ( babinski relfex) https://en.wikipedia.org/wiki/Hepatic_encephalopathy