1. HEPATIC ENCEPHALOPATHY Dr. Ghulam Hussain Baloch Associate Professor of Medicine Liaquat University of Medical & Health Sciences, Jamshoro

2. Definition It is a state of disordered CNS function, resulting from failure of liver to detoxify toxic agents because of hepatic insufficiency and porto-systemic shunt.

3. Toxic Agents Ammonia NH 3 Mercaptin Free Fatty Acids

4. Pathogenesis Ammonia formed by protein breakdown in GIT Liver  Converts NH3 into urea  Excreted by kidney

5. Pathogenesis Ammonia formed by protein breakdown in GIT Liver  liver dysfunction (abnormal)  NH3  Passes BBB  Hepatic encephalopathy.

6. Precipitating Agents (A)Increase Nitrogen Load (a)Constipation. (b)Gastro intestinal bleeding. (c)Excess dietary intake of protein & fatty acids. (d)Azotemia.

7. Precipitating Agents (B)Infections & Trauma (Surgery). (C) Electrolyte & Metabolic imbalance Hypokalemia. Alkalosis. Hypoxia. Hyponatremic.

8. Precipitating Agents (D)Drugs Diuretics, Narcotics, Tranquilizers, Sedatives.

9. Clinical Features Symptoms Sleep disturbances. Personality Changes. Confusion. Slurred Speech. Deterioration. Drowsiness. Coma. Fever, Nausea, Vomiting and Techypnea are also common.

10. Clinical Features Signs Fetar Hepaticus. Flapping Tremors or Asteritxis. Coma.

11. Clinical Staging Stage-I Euphoria or Depression Mild Confusion Slurred Speech Disordered Sleep

12. Clinical Staging Stage-II Moderate Confusion. Lethargy

13. Clinical Staging Stage-III Marked Confusion. Incoherent Speech. Sleeping but Arrousable. Stage-IV Coma.

14. Investigation (1)Liver function test. (2)Serum Electrolytes. (3)EEG. (4)Arterial Blood Ammonia. (5)Blood gases.

15. Management General Measures (1)Hospitalize the patient. (2)Identify and remove the precipitating factors. (3)Stop or reduce the Diuretic Therapy. (4)Correct any electrolyte imbalance. (5)Reduce the ammonia (NH3) Load. Treat Constipation by Laxatives

16. Management Drug Lactulose Mechanism of Action It produces osmosis of water- Diarrhea. It converts NH3- NH4 that can be excreted.

17. Treat the GIT & other Infections GIT- Infection Supers the normal flora of GIT with Metronidazole Vacomycin. Other Infection Third generation ephalosporin

18. Variceal Bleeding The collaterals at oesophagogastric junction due to porto-systemic shunt one known as oesophageal varices. The varices can rupture in 1/3 cases and can lead to death in 50% cases.

19. Clinical Feature Melena (black colour stools) Hematemis Hypovolumic shock

20. Management Treatment during active-bleeding. (1)Monitor the vitals (2)Pass I/V line and give blood transfusion.(if not available give plasma expander). (3)FFP(Fresh Frozen Plasma) can be given in case of thrombocytopenia. (4)I/V H2 receptor blocker or proton pump inhibitors (Omeperazole) can be given to reduce gastric irritation.

21. Vasoconstriction Agents (1)Vasopression Side-effect - angina or MI. (2)Terlepression More safe as compared to vasopression. (3)Octreotide Also decreases secretion in GIT.

22. Urgent Endoscopy and Sclerotherapy After stoppage of bleeding with the help of vasoconstricting agent and when patient becomes hemodynamically in stable condition, then injection sclerotherapy can be given.

23. Urgent Endoscopy and Sclerotherapy Sclerosing agent Ethanolamine tetradecyl sulfate. OR Banding - can be performed by putting rings at basis of varices.

24. Other Measures (1) Balloon Temponade The sangstaken- black more tube is passed into the stomach and the balloon is inflated and pulled back, which exerts pressure on lower oesophages and fundus to stop the bleeding.

25. Other Measures (2) Le-Vein Shunt A shunt is passed sub-cutaneously in between the jugular vein and portal vein.

26. Other Measures (3) TIPS (Transjular Intrahepatic Porto- caval Shunt) In this procedure a catheter is passed from jugular vein to portal vein under the u/s guidance.

27. Prophylais Agaist Re-Bleeding Once the initial episode of bleeding is controlled, the risk of rebleeding is 50- 80% without further therapy. (1)Long term injection sclerotherapy usually 4-6 treatment one required to prevent rebleeding, but every year endoscopy should be done to see the condition of varices.

28. Prophylais Agaist Re-Bleeding (2)B- Blockers (Non selective beta- blocker of propranolol) It dilates the protal veins so decrease the portal vein pressure. In case of asthmatic patient glyceryl dinitrite can be used.

29. Thanks