Internal Medicine · Year 3 · from Internal Medicine
Case 2: Hepatic Encephalopathy
Patient Presentation
A 62-year-old woman with cirrhosis secondary to nonalcoholic steatohepatitis (NASH) is brought in by her family for confusion and erratic behavior over the past 3 days. They report she has been sleeping during the day, awake at night, and yesterday did not recognize her grandchildren. She missed her last GI appointment and ran out of lactulose 1 week ago.
Vital Signs
- Blood Pressure: 112/68 mmHg
- Heart Rate: 78 bpm
- Respiratory Rate: 16/min
- Oxygen Saturation: 97% on room air
- Temperature: 36.9°C
Physical Examination
- General: Somnolent but arousable, disheveled
- HEENT: Icteric, fetor hepaticus
- Cardiovascular: Normal
- Abdomen: Moderate ascites, splenomegaly
- Neurologic: Disoriented to time and place, asterixis present, slow responses, no focal deficits
- Skin: Spider angiomata, palmar erythema
Laboratory Results
- Ammonia: 142 μmol/L (elevated, normal <35)
- Sodium: 132 mEq/L
- Creatinine: 1.3 mg/dL
- Blood glucose: 98 mg/dL
- Urinalysis: Negative for infection
- CBC: WBC 5,200/μL, normal differential
Clinical Image
Figure 2: Demonstration of asterixis (flapping tremor) - intermittent lapses of sustained posture when wrists are dorsiflexed, characteristic of hepatic encephalopathy.
Image Source: Educational illustration for teaching purposes.
Questions
- What is the West Haven criteria grade of this patient's hepatic encephalopathy?
- A) Grade I - mild
- B) Grade II - moderate
- C) Grade III - severe (somnolent but arousable)
- D) Grade IV - coma
- What are common precipitants of hepatic encephalopathy?
- A) Hyperglycemia only
- B) GI bleeding, infection, constipation, medications (sedatives, opioids), electrolyte abnormalities, dehydration, dietary protein excess, medication non-adherence
- C) High carbohydrate diet
- D) Exercise
- What is the first-line treatment for hepatic encephalopathy?
- A) Antibiotics alone
- B) Lactulose (titrate to 2-3 soft bowel movements daily)
- C) Protein restriction
- D) Benzodiazepines
- What is the role of rifaximin in hepatic encephalopathy?
- Should dietary protein be restricted in hepatic encephalopathy?
Answers
- C) Grade III - severe (somnolent but arousable) - West Haven criteria:
- Grade I: Mild confusion, short attention span, sleep-wake reversal
- Grade II: Lethargy, moderate confusion, disorientation, asterixis
- Grade III: Somnolent but arousable, marked confusion, incoherent speech
- Grade IV: Coma, unresponsive
- This patient is somnolent but arousable with disorientation = Grade III
- B) GI bleeding, infection, constipation, medications (sedatives, opioids), electrolyte abnormalities, dehydration, dietary protein excess, medication non-adherence - Always search for precipitants:
- GI bleeding (increased nitrogen load)
- Infection/SBP
- Constipation
- Medications (benzodiazepines, opioids)
- Hypokalemia, hyponatremia
- Dehydration/AKI
- Dietary indiscretion
- Non-adherence to lactulose (this patient)
- B) Lactulose (titrate to 2-3 soft bowel movements daily) - Lactulose mechanism:
- Non-absorbable disaccharide
- Acidifies colonic contents (traps ammonia as NH4+)
- Cathartic effect (removes nitrogen)
- Dose: 25-30 mL (15-30 g) every 1-2 hours until bowel movement, then titrate
- Maintenance: 25-30 mL 2-4 times daily for 2-3 soft stools/day
- Role of rifaximin:
- Non-absorbable antibiotic targeting gut flora
- Added to lactulose for prevention of recurrent HE (secondary prophylaxis)
- Dose: 550 mg twice daily
- RFHE trial showed 50% reduction in recurrent HE
- Expensive; generally reserved for recurrence despite lactulose
- Not typically used for acute HE treatment alone
- Protein restriction is NOT recommended:
- Historical practice of protein restriction is harmful
- Cirrhotic patients are often malnourished and catabolic
- Protein restriction worsens muscle wasting and outcomes
- Recommended intake: 1.2-1.5 g/kg/day protein
- Vegetable and dairy protein may be better tolerated than animal protein
- Branched-chain amino acids (BCAA) supplements may help if intolerant