083. Hepatic Disorders, Jaundice, and Hepatic Failure

Hepatitis B

Recent research shows promise with Tenofovir (HIV medication). Recent study showed it actually reversed cirrhosis changes in patients given it for 5 years. (Marcellin, Lancet 2013)

Coagulation in End Stage Liver Disease

Liver synthesizes both anti and pro-coagulation cascade so because both are decreased in liver disease, actually evens out. INR useless (only useful for warfarin use). There is no single test to determine coagulation affect in liver disease (PT, PTT, bleeding time, etc).

Hepatic Encelopathy

Systemic complication of liver dx. Transient and reversible neuro and psychiatric manifestations. Poor prognostic indicator

 Symptoms: mild neuro disturbance, forgetfulness, nystagmus, asterixis – flapping hand tremor, agitation, seizures, ultimately coma

Causes: Gi bleed, infection, noncompliance, dehydration, hepatorenal syndrome. Colon flora creates ammonia – goes into liver and gets converted and excreted in urine. With cirrhotic, pathway inhibited and ammonia floating around. Cerebellum and basal ganglia pick it up and cause abnormalities and disturbance in neuro transmission

Diagnosis:

Level of ammonia tends to be elevated – poorly correlates with grade of hepatic encelopathy. Little clinical value. Need to diagnosis CLINICALLY.

Grade 2: lethargy, gross intellectual impairment, asterixis – ADMISSION

Grade 3: somnolence, amnesia, bizarre behavior, nystagmus/clonus

Grade 4: stupor to unconscious, comatose, dilated pupils. HIGH mortality

Tx: Eliminate precipitating event. Remove excess ammonia – lactulose ORAL (non absorbable sugar and changes pH of gut – ammonia charged and can’t get absorbed. SE: electrolyte abnormalities and dehydration). Abx: neomycin (ototoxicity/nephrotoxicity) & rifaximin. Supportive care. Low protein diet / Probiotics. Flumazenil – blocks GABA, pt temporarily wakes up and goes back to asleep – able to check in ICU to see how patient is doing

References/Resources

USC Grand Rounds – Lopez – Hepatic Encephalopathy – 15 min video

EMRAP, Rob Orman, April 2014, Notes from the Community – Coagulopathy in End Stage Liver Disease

083. Hepatic Disorders, Jaundice, and Hepatic Failure

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