Hepatic Encephalopathy

Pt with h/o liver cirrhosis, portal hypertension presents with acute onset confusion. Family reports recent changes in memory, personality, concentration. Denies recent head trauma. Normal SPO2, impaired attention, decreased decreased response time bradykinesia, hyperreflexia, rigidity, myoclonus, asterixis on exam. MMSE score <24.

• Obtain CBC, CMP, fingerstick, ammonia level, ABG, FOBT

• Head CT shows no signs of intracranial bleed or acute pathology

• Eliminate sedating medications

• Start lactulose 30mL PO TID; titrate to 3 BMs/day, max dose 300mL/day

• Confusion continues with lactulose 300mL/day; start neomycin 4g q6h; titrate to 12g q6h

• Condition refractor to lactulose, neomycin; consider starting flumazenil

• Pt advised to abstain from alcohol

• Pt counseled that long-term therapy may involve liver transplant

Notes

• Hepatic encephalopathy may be exacerbated by endogenous benzodiazepines

• Flumazenil is a benzodiazepine receptor antagonist

• Protein restricted diet does not improve symptoms