Jan 291 min read

Hepatic Encephalopathy & Hyperammonemia - #MEDSHED

Updated: Feb 5

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🚚 Hepatic Encephalopathy & Hyperammonemia - #MEDSHED

🤔 General

Neuropsychiatric complication of cirrhosis and/or porto-systemic shunting. Cirrhosis leads to impaired hepatic metabolism of ammonia. Cerebral edema develops from swollen astrocytes metabolizing excess ammonia in the brain.

Clinical Presentation

Nonspecific neurologic and psychiatric effects

AMS

Unresponsive

Hypertonia

Muscle rigidity

Hypokinesia

Advanced liver disease

Jaundice

Muscle wasting

Ascites

Sarcopenia

Acute Pharmacotherapy

Reduce production of ammonia and maximize removal of ammonia. Maintain potassium replacement as hypokalemia reduces renal elimination of ammonia. Address precipitating factors.

Lactulose

Hyperosmolar laxative that changes gastric pH, trapping intestinal ammonia, and processed for elimination

Rifaximin

20- 30 gm solution PO/FT q 1 - 2 hours PRN 2 to 3 bowel movements/day

200 gm enema rectally q 4 - 8 hours PRN

Rifaximin

Antibiotic that inhibits bacterial RNA synthesis, reduces ammonia-producing enteric organisms

Lactulose with rifaximin resolves HE more rapidly than lactulose alone

550 mg po BID

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