You have been asked to review a 53-year-old patient with known alcoholic liver disease. The patient has had a progressive fall in consciousness level over the last 24 hours and the medical team are concerned about the development of hepatic encephalopathy (HE).
a) List four alternative diagnosis to HE that you would consider in this circumstance. (20% marks)
b) List six clinical signs that would be suggestive of HE. (30% marks)
c) Discuss the specific management of severe HE in this setting. (50% marks)
Why is this alcoholic now comatose? The possibilities are endless:
Clinical signs of hepatic encephalopathy could include:
Management of severe hepatic encephalopathy (presumably they expected just the specific management) could include:
Specific management of hepatic encephalopathy
Management of the precipitating cause
Additional supportive management steps could include:
Lastly, a reader had suggested quad-H therapy as one of the possible options to list here (hyperventilation, haemodiafiltration, hypernatraemia and hypothermia) but this is usually a management strategy used to treat the cerebral oedema of acute liver failure rather than the encephalopathy of chronic liver disease. It is impossible to tell whether this would have scored any marks, and the authors own instinct is that it would not. The reader is left to make up their own mind.
Wijdicks, Eelco FM. "Hepatic encephalopathy." New England Journal of Medicine 375.17 (2016): 1660-1670.
Blei, Andres T., and Juan Córdoba. "Hepatic encephalopathy." The American journal of gastroenterology 96.7 (2001): 1968-1976.
Prakash, Ravi, and Kevin D. Mullen. "Mechanisms, diagnosis and management of hepatic encephalopathy." Nature Reviews Gastroenterology and Hepatology7.9 (2010): 515-525.