Hepatic Encephalopathy

Lactulose 15 - 45 ml PO bid - qid, to produce 3 - 5 soft stools daily.

+/- Neomycin, 500 - 1000 mg PO q6h

If Pt. unable PO

Lactulose enemas: Add 300 ml + 700 ml distilled water

Neomycin retention enema, 1% sol. in 100 - 200 ml NS. Caution: Ototoxic/nephrotoxic. C/I in CRI.

Lactulose preferable over neomycin.

 Hepatic encephalopathy usually appears in a patient with liver function old ready compromise from alcoholic cirrhosis, chronic hepatitis, or malignancy. An increased protein load, such as from GI bleed, close ammonia to accumulate in the brain. Whether the high level of ammonia itself or the increase in concentration of its metabolites produces the alterations in consciousness is not known. Examination may reveal abdominal ascites, and enlarged or shrunken liver, and Ace to excess, in addition to changes in mental status, namely in attention, disorientation, and confusion. In the later stages, focal signs such as hemiparesis or dysconjugate gaze may appear.

Although ammonia levels can be elevated in the setting of hepatic encephalopathy, the ammonia level does not necessarily need to be abnormal to make this diagnosis, nor should ammonia be tracked as a marker of disease resolution.  Likewise, other diagnostic tests, such as brain imaging and EEG, can be normal or abnormal in patients with hepatic encephalopathy. 

 Management is directed at reducing the protein load with diet reporting restrictions and neomycin   2-4 g  p.o. daily or rifaxamin, 200 mg p.o. b.i.d., which reduces the population of ammonia producing bacteria and the bowel. Lactulose 15-45 mL to 4 times a day to induce diarrhea may also help reduce intestinal bacteria. chest is acute agitation requires treatment, use benzodiazepine such as diet soup and 5-10 mg every 8 hours. Haloperidol should be avoided. Check coagulopathy states.