MANAGEMENT OF HEPATIC
ENCEPHALOPATHY
DR RAMYA J
POST GRADUATE
PROF UMAKANTHAN’S UNIT
MANAGEMENT
CONTROL PRECIPITATING FACTORS
GI bleed - variceal or non variceal
Infections - SBP, pneumonia ,UTI
Dietary protein - excess animal protein
Electrolyte imbalance - diuretics
Constipation
Use of sedatives and tranquilisers
Azotemia - catabolic states /
hepatorenal
syndromes, GI bleed / drug
induced
Acute hepatic decompensation – hepatotoxic drugs
/reactivation
of hepatotropic virus
Surgery / shunts
SUPPORTIVE THERAPY
• Cerebral edema : mannitol 1gm/kg body wt
• Respiratory failure : oxygen , mechanical
ventilation
• Infection : appropriate antibioics
• Bleeding : varecial ligation / transfusion
• Treatment of hypoglycemia , hypokalemia,
hypocalcemia
• Bowel and bladder care
EMPERIC THERAPY
• BASED ON AMMONIAGENIC SUBSTRATES
1 ) Reduction of ammoniagenic substances
enema / cathartics
ideal – whole bowel clensing with acidic enemas
done 3 - 4 times / day
Dietary protein restriction
o Dietary protien witheld during acute episode
o Resumption of oral intake / 20gms/day with
10gm incriments every 3 – 5 days to limit of
1gm / kg body wt
o Maintain positive protein balance
o Avoid prolonged and gross protein restriction
Continued….
• Recommended daily protein intake
European Society For Parenteral
& Enteral Nutrition Consensus
Guidelines – 1 to 1.5 gm/kg
• Vegetable protein preferred- less
ammoniagenic , high fibre content ,
less AAA
Continued…
2) Decreased ammonia production
non absorbable disachharides
LACTULOSE ( beta galactosidofructose )
broken down by colonic bacteria to acetic and
lactic acid - decreases colonic PH
Decreased PH converts ammonia to ammonium iron
Decreased PH hostile to survival of urease
producing intestinal bacteria. Increases growth of
lactobacillus
Cathartic
For acute HE initial 45ml P O / n g tube hourly till
evacuation , adjust to 30ml tds to obtain 2-3 soft
bowel movements / day
For chronic HE initial hourly dosing not required
Side effects : flatulence / diarrhoea /
ileus / metabolic alkalosis
LACTILOL ( beta galactosido sorbitol )
2nd generation disaccharide available
as crystalline powder
0.5gms/kg/day
Used in patients intolerant to lactulose
Less side effects , less sweet , quicker
onset
ANTIBIOTICS:
Inhibit the growth of urealytic and proteolytic
bacteria
Decreases glutaminase activity , generation of
methionine and related products
neomycin, metronidazole, paromomycin , rifaximin
Acute encephalopathy -
neomycin 3-6 gms/day oral x 1-2 weeks . Prolonged
administration – oto-nephro toxicity , diarrhoea and
super infection
Metronidazole 250 mg tds
Chronic encephalopathy –
Neomycin 1gm/day with periodic renal and auditory
monitoring
Rifaximin 400 mg tds
3) Increased metabolic ammonia removal
amonnia removed by formation of urea and
synthesis of glutamine
L ORNITHINE L ASPARTATE ( LOLA )
provides substrate for urea cycle
( ornithine ) as well as syn of
glutamine(aspartate)
Available as oral/iv
SODIUM BENZOATE/SODIUM PHENYLACETATE
Benzoate + glycine = hippurate – renal
excretion with loss of ammonia
Phenyl acetate + glutamine = phenyl
acetyl glutamine – renal excretion with
loss of ammonia
Based on GABA hypothesis :
Increased GABAergic tone increases
inhibitory neurotransmitters
Flumazenil ( benzodiazepine receptor
antagonist)
Administered iv , short acting
Oral preparation not available for long
term use
EMPERIC THERAPY
(CONTINUED)
Based on false neurotransmitter hypothesis
Branched chain aminoacids
• In HE altered ratio of BCAA and AAA
• Deficiency of BCAA and high AAA worsens
encephalopathy by producing false
neurotransmitters
• BCAA – parenterally administered
• Maintains positive nitrogen balance
• DOPA AND BROMOCRIPTINE:
In HE - decrease the activity of dopaminergic
neuro transmission
Bromocriptine 30 mg bd improves encephalopathy
EMPERIC THERAPY CONTINUED
Zinc replacement :
• Zinc deficiency common especially in cirhosis
• Cofactor in urea cycle enzymes
• Zn SO4 / Zn acetate 600 mg O D
Correction of manganese deposition in basal ganglia :
• Studies needed to demonstrate therapeutic effect of
Mn chelation
Probiotics
• Idea of populating colonic lumen with non urease
producing bacteria – lactobacilus acidophilus,
enterococcus fecium
Eradication of H pylori
Disaccharide inhibitors
• Acarbose allows undigested disaccharides to reach
colon
• No advantage over lactulose
SURGICAL THERAPY
• Shunt occlusion with coils
• Temporary liver support –
extracorporeal haemoperfusion
• Orthoptic liver transplant
LIVER DIALYSIS UNIT
LIVER DIALYSIS UNIT
LIVER X 2000
MARS - Molecular Adsorbent
Recycling System
MARS -MEMBRANE
MELS – Modular
Extracorporeal Liver
System
MELS Membrane
ELAD – Extra corporeal
Liver Assist Device
