Question 30

You have been asked to review a 53-year-old patient with known alcoholic liver disease, who has had a progressive fall in conscious level over the last 24 hours. The medical team are concerned the patient is developing hepatic encephalopathy (HE).
a) List four alternative diagnoses to HE that you would consider in this circumstance.    (1 marks)
b) List six clinical signs that would be suggestive of HE.    (3 marks)
c) Outline the specific management of severe HE in this setting.    (6 marks)

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Syllabus topic/section:

2.1.6    Gastrointestinal Intensive Care – L1.
Aim:

To explore a common clinical diagnostic challenge in a common hepatology pathology.

Discussion:

This question was repeated from the 2017.2 paper and the percentage scoring >5/10 was 26.5 %. The current pass rate has remained similar to the last published appearance of this SAQ. The answer has not changed since SAQ answer publication in 2017.

Most of the candidates who were unsuccessful did not demonstrate the difference between fulminant acute hepatic failure and decompensated chronic liver disease. Mentioning that HE is a diagnosis of exclusion with a brief succinct summary outlining the specific management of this pathology were a feature of the better candidates answer.

Discussion

Question 10 from the second paper of 2017 which was referred to in the college comments is an excellent reference here because it contains a very detailed college answer.

a) 

Possible causes of unconsciousness in the middle-aged alcoholic could be anything, considering also that we are not given any better description of it (i.e. it could represent merely confusion rather than coma). 

The top four would have to be:

  • Hypoglycaemia
  • Intracranial haemorrhage, eg. a subdural haematoma from a fall
  • Intoxication - i.e. this patient may have access to alcohol while in hospital, or may have drunk something which is not exactly ethanol (eg. chlorhexidine-based hand wash)
  • Seizures, eg. associated with withdrawal

Other possibilities include:

  • Stroke, including cerebral venous sinus thrombosis
  • CNS infection
  • Septic encephalopathy
  • Hyponatremia
  • Space-occupying lesion

b)

Clinical signs which might suggest HE can be extracted from this ancient grading system which was developed by Conn and Lieberthal (1979)

Physical Signs in Hepatic Encephalopathy

Stage I

  • Metabolic tremor
  • Muscular incoordination
  • Impaired handwriting

Stage II

  • Slurred speech
  • Asterixis
  • Hypoactive reflexes
  • Ataxia

Stage III

  • Hyperactive reflexes
  • Nystagmus
  • Babinski’s sign
  • Clonus
  • Rigidity

Stage IV

  • Dilated pupils
  • Opisthotonus
  • Coma

Specific management of hepatic encephalopathy

  • Lactulose, or lactose if they are lactose-intolerant
  • Rifaximin
  • Avoidance of hyponatremia
  • Nutritional management:
    • Branched-chain amino acids (BCAAs) and a reduced amount of aromatic amino acids
    • High fiber diet
    • Pro-biotics (though their benefit is unclear)
    • Optimise nutrition (35-40kcal/kg/day)
    • High protein intake (1.2-1.5g/kg/day)

Management of the precipitating cause

  • Stop GI bleeding (endoscopy, banding, etc)
  • Antibiotics for SBP
  • Correct dehydration
  • Withdraw hepatotoxins

Supportive management of the encephalopathic patient

  1. Noradrenaline +/- terlipressin may be appropriate if hepatorenal syndrome is suspected
    Albumin (20%) is a reasonable resuscitation fluid
  2. Ensure BSL is monitored and supplemental glucose is made available
  3. Ensure thiamine is co-administered with glucose
  4. Address haematinic factor deficiencies.
  5. Antibiotics as appropriate: ceftriaxone may be required if SBP is a real possibility.

References

Blei, Andres T., and Juan Córdoba. "Hepatic encephalopathy." The American journal of gastroenterology 96.7 (2001): 1968-1976.

Ferenci, Peter, et al. "Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998." Hepatology 35.3 (2002): 716-721.

Prakash, Ravi, and Kevin D. Mullen. "Mechanisms, diagnosis and management of hepatic encephalopathy." Nature Reviews Gastroenterology and Hepatology7.9 (2010): 515-525.

Nabi, Eiman, and Jasmohan S. Bajaj. "Useful Tests for Hepatic Encephalopathy in Clinical Practice." Current gastroenterology reports 16.1 (2014): 1-8.

Guillén, Juan C. Quero, and Juan M. Herrerías Gutiérrez. "Diagnostic methods in hepatic encephalopathy." Clinica chimica acta 365.1 (2006): 1-8.

Shawcross, Debbie L., and Julia A. Wendon. "The neurological manifestations of acute liver failure." Neurochemistry international 60.7 (2012): 662-671.

Conn, Harold O., and Milton M. Lieberthal. The hepatic coma syndromes and lactulose. Williams & Wilkins, 1979. - this is a book, and not available for free online.