肝性脑病

Hepatic Encephalopathy 肝性脑病
问题： 1 本病例完整诊断是什么? 2 进一步明确诊断还需做那些检查？ 3 如何治疗？
认识事物的规律
请不要盲人摸象，要从总体上把握整个事物
肝性脑病的认识思路
什么是肝性脑病？（定义） 什么情况下应考虑肝性脑病的可能（临床表现） 怎样明确是肝性脑病（诊断和排除/鉴别诊断,
Evoked potentials ❖ Variation, lack of specificity and sensitivity
Diagnosis & differential diagnosis
Programme of diagnosis
❖ the clues for the diagnosis ❖ supportive Proof for the diagnosis ❖ Exclusion of other similar diseases(differential
Pathogenesis
Postulated factors/mechanisms:
Ammonnia neurotoxicity Synergistic neurotoxins Excitatory inhibitory neurotransmitters plasma amino acid imbalance hypothesis γ-Aminobutyric acid hypothesis
A patient with severe and dysfunctional liver disease or /and portal hypertension in the conditions as: ➢ Disturbed consciousness/coma/death ➢ Personality changes ➢ Intellectual deterioration ➢ Speech ➢ Flapping tremor (asterixis) ➢ Fetor hepaticus ➢ Increased serum ammonia level
Identification and Removal of Precipitating Factors
➢A vigorous search to identify and eliminate a precipitating factor or factors should be immediately instituted.
Clinical manifestation
❖ Disturbed consciousness
➢ Slowness, ➢ Somnolence ➢ Disorientation ➢ Confusion ➢ deep coma ➢ Death
❖ Personality changes
➢ childishness ➢ irritability
Treatment
TREATMENT GOALS
Provision of Supportive Care ➢Adequate supportive care is critical during all stages of HE and may involve other professionals in the provision of patient care.
diagnosis ❖ complete diagnosis(including etiology, stage,
subtype, precipitating factors,and other complications of cirrhosis
Clues for the diagnosis of HE
Incidence/prevalence
❖ Universal feature of acute liver failure ❖ 50%~70% in chronic hepatic failure ❖ Difficult tatic failure --Due to acute hepatocellular necrosis ❖ acute severe viral hepatitis, drug/toxin ❖ acute fatty liver of pregnancy
HE---common precipitating
factors
Nitrogenous
Non-Nitrogenous
Encephalopathy
Encephalopathy
Uremia/azotemia Gastrointestinal bleeding Dehydration Metabolic alkalosis Hypokalemia Constipation Excessive dietary protein Infection
Clinical manifestation
In chronic liver disease ❖ Insidious onset ❖ Characterized by subtle and/or intermittent changes in
➢ consciousness ➢ Personality ➢ intelligence ➢ speech
Supportive proof for the Diagnosis
Patients with severe liver disease and/or portal hypertension, portosystemic shunting
Factors precipitating or aggravating HE exist Mental changes: confusion, somnolence, coma Flapping tremor Severely impaired liver function and/or
Reduction of Nitrogenous Load From the Gut ➢Measures to reduce the nitrogenous load from the gut should be implemented.
Assessment of the Need for Long Term Therapy Patients with cirrhosis are at risk of developing new episodes of encephalopathy . At discharge, three factors need to be considered: ➢Control of potential precipitating factors ➢Higher likelihood of recurrent encephalopathy ➢Assessment of the need for liver transplantation
Ammonia neurotoxicity
Ammonia elimination ❖ Transfer to the liver ❖ Metabolized by series of urea cycle enzymes ❖ Consumpted by brain, liver, kidney: to synthesize glutamic acid and glutamine ❖ Excreted into the urine ❖ Eliminated by lung (trace amounts)
Differential diagnosis
Hypoglycemia Uremia Diabetic ketoacidosis Nonketotic hyperosmolar syndrome Subdural hematoma Cerebrospinal infection Others: lupus encephalopathy, alcoholic encephalopahty
Clinical manifestation
Criteria for clinical stages ➢ Personality and mental changes ➢ Abnormal EEG patterns ➢ Asterixis
Clinical stages of HE
Clinical stages of HE
Definition (2)
“Portal-systemic encephalopathy” patients with portal hypertension abnormal shunting of blood
“Subclinical or latent HE” diagnosed only by using precise mental tests or EEG
hyperammonemia typical EEG changes
Diagnosis
latent and/or subclinical HE In the absence of characteristic features ❖ Abnormal neuropsychiatric function: ❖ Reitan trial test ❖ Digit symbol tests ❖ Block design ❖ Visual reaction times
肝性脑病的完整诊断思路） 如何治疗肝性脑病？
Definition (1)
Hepatic encephalopathy (HE) It represents a reversible decrease in
neurologic function, based upon the disorder of metabolism which are caused by severe decompensated liver disease