135 Hepatic Encephalopathy SPECIFIC ENTITIES (CONT’D) diagnosis of exclusion (especially important to rule out ATN and pre renal causes) Check for infection and GI bleed TREATMENTS stop diuretics, fluid (usually no response), albumin, vasoconstrictors (midodrine, octreotide, norepinephrine), TIPS, renal replace ment therapy, liver transplant FLOOD SYNDROME (SPONTANEOUS UMBILICAL HERNIA RUPTURE) PATHOPHYSIOLOGY liver failure ! portal hyper tension ! ascites ! umbilical hernia (up to 20%) ! spontaneous rupture (rare) DIAGNOSIS SPECIFIC ENTITIES (CONT’D) 50% mortality with supportive care, 10 20% mortality with urgent surgical repair PROGNOSIS Related Topics Acute Hepatic Failure (p 128) Ascites (p 136) Encephalopathy (p 135) Hemochromatosis (p 420) Hepatitis B (p 130) Hepatitis C (p 131) Jaundice (p 138) Hepatic Encephalopathy NEJM 1997 337:7 DIFFERENTIAL DIAGNOSIS DRUGS acute intoxication, withdrawal, Wernicke Korsakoff PSYCHOACTIVE benzodiazepines, cocaine, her oine, ecstasy OTHERS salicylates INFECTIOUS pneumonia, UTI, meningitis, ence phalitis, abscess, spontaneous bacterial peritonitis METABOLIC ORGAN FAILURE hepatic, azotemia, hypothyroid ism, hypoxemia, CO2 narcosis ELECTROLYTES ketoacidosis, hyponatremia, hypo magnesemia, hypercalcemia, glucose (hypo, hyper) STRUCTURAL HEMORRHAGE subarachnoid, epidural, subdural, intracerebral STROKE basilar PATHOPHYSIOLOGY (CONT’D) " DIFFUSION ACROSS BLOOD–BRAIN BARRIER alkalosis # METABOLISM dehydration, hypotension, hypox emia, anemia, portosystemic shunt, hepatoma, progressive liver damage ALCOHOL CLINICAL FEATURES HISTORY characterize confusion (onset, duration, fluctuation), infectious symptoms, neurological symptoms, precipitants (diet, hydration, constipation, GI bleed, infection), past medical history (liver dis ease, alcohol and illicit drug use), medication history (sedatives, narcotics) PHYSICAL vitals, signs of chronic liver disease, rec tal examination (if suspect GI bleed), neurological examination, check for asterixis TUMOR INVESTIGATIONS EPILEPSY BASIC NEUROPSYCHIATRIC CBCD, lytes, urea, Cr, glucose, TSH, AST, ALT, ALP, bilirubin, INR, PTT, NH4, Ca, Mg, PO4, osmolality, CK, troponin (as part of delirium workup), urinalysis MICROBIOLOGY blood C&S, urine C&S, sputum Gram stain/C&S IMAGING U/S abd, CT abd ASCITIC FLUID ANALYSIS cell count and diff, C&S to rule out SBP SPECIAL CT HEAD delirium workup ABG if critically ill GASTROSCOPY to check for varices PATHOPHYSIOLOGY GRADING OF HEPATIC ENCEPHALOPATHY reversed sleep cycle, mild confusion, tremor, incoordination lethargy or irritability, disoriented to time, asterixis, ataxia somnolence or agitation, disoriented to place, asterixis, hyperreflexia, positive Babinski coma, decerebrate PRECIPITANTS OF HEPATIC ENCEPHALOPATHY " NH4 PRODUCTION " protein intake, constipation, GI bleed, transfusion, infection (spontaneous bac terial peritonitis), azotemia, hypokalemia LABS LIVER BIOPSY EEG symmetric, high voltage, slow wave pattern 136 Ascites MANAGEMENT MANAGEMENT (CONT’D) ACUTE HEPATIC ENCEPHALOPATHY WORKUP FOR SEPSIS consider sedation (haloperidol mg PO/IV/SC q6h and q1h PRN) and ventila tion, mannitol g/kg 20% solution, acetylcysteine, epoprostenol TREAT UNDERLYING CAUSE liver transplant SYMPTOM CONTROL CHRONIC HEPATIC ENCEPHALOPATHY protein restriction no longer routinely recommended Lactulose 30 g PO BID QID PRN titrate to bowel movements/day or SYMPTOM CONTROL 300 mL lactulose mixed with 700 mL H2O PR if NPO (also lactitol and lactose) Neomycin 500 2000 mg PO q8h or metronidazole 800 mg PO daily (alter natives to lactulose or use in combination) Others (H pylori treatment, ornithine aspartate, branched amino acids) TREAT UNDERLYING CAUSE liver transplant Related Topic Delirium (p 380) Ascites NEJM 2004 350:16 DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS (CONT’D) " HYDROSTATIC PRESSURE CARDIAC right heart failure, tricuspid regurgita tion, constrictive pericarditis HEPATIC pre sinusoidal (portal vein thrombo sis, schistosomiasis), sinusoidal (cirrhosis), post sinusoidal (Budd Chiari, veno occlusive) # ONCOTIC PRESSURE malnutrition, liver dis ease, nephrotic, protein losing enteropathy " CAPILLARY PERMEABILITY/LYMPHATIC OBSTRUCTION INFECTIONS spontaneous bacterial peritonitis MALIGNANCY ovarian, peritoneal metastasis PANCREATITIS OTHERS hypothyroidism CLINICAL FEATURES RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE ASCITES? Sens Spc LR+ LR History " abdominal girth 87% 77% 4.16 0.17 Recent weight gain 67% 79% 3.2 0.42 Ankle swelling 93% 68% 2.8 0.10 Hepatitis 67% 79% 3.2 0.42 Heart failure 47% 73% 2.04 0.73 Alcoholism 60% 58% 1.44 0.69 Hx of carcinoma 13% 85% 0.91 1.01 Physical Bulging flanks 81% 59% 2.0 0.3 Flank dullness 84% 59% 2.0 0.3 Shifting dullness 77% 72% 2.7 0.3 Fluid wave 62% 90% 6.0 0.4 APPROACH ‘‘most useful findings for ruling out ascites are negative history of ankle swelling, " abdominal girth, and negative for bulging flanks, flank dullness, or shifting dullness Most powerful findings for making diagnosis of ascites are positive fluid wave, shifting dullness, or peripheral edema Puddle sign and auscultatory percussion not recommended’’ JAMA 1992 267:19 INVESTIGATIONS INVESTIGATIONS (CONT’D) BASIC PARACENTESIS CBCD, lytes, urea, Cr, AST, ALT, ALP, bili rubin, INR, PTT, albumin, amylase, lipase, TSH, urinalysis IMAGING U/S abd, CT abd LABS cell count + diff, Gram stain, C&S, AFB, albumin, LDH, glucose, amylase, triglycer ide, cytology SPECIAL LAPAROSCOPY WITH PERITONEAL BIOPSY 137 Ascites DIAGNOSTIC ISSUES RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE BACTERIAL PERITONITIS OR PORTAL HYPERTENSION? HOW DO I PERFORM A PARACENTESIS AND ANALYZE THE RESULTS? PARACENTESIS TECHNIQUE two studies showed that testing for coagulation prior to paracentesis was probably unnecessary; one study showed that a 15 gauge, 3.25 in needle cannula was associated with less multiple peritoneal punctures and termina tion due to poor fluid return as compared to a 14 gauge needle in therapeutic paracentesis; one study showed immediate as compared to delayed inoculation of culture bottles improved diagnostic yield (100% vs 77%); nine studies examined thera peutic paracentesis with or without albumin or non albumin plasma expanders and found no consistent effect on morbidity or mortality FEATURES SUGGESTIVE OF SPONTANEOUS BACTERIAL PERITONITIS LR+ LR Ascitic fluid WBC/PMN Ascitic fluid WBC >1000 cells/mL 9.1 0.25 Ascitic fluid WBC >500 cells/mL 5.9 0.21 Ascitic fluid WBC >250 cells/mL 0.9 1.1 Ascitic fluid PMN >500 cells/mL 10.6 0.16 Ascitic fluid PMN >250 cells/mL 6.4 0.20 Ascitic fluid pH and blood ascitic pH gradient Ascitic fluid pH 250 cells/mL) or blood ascitic fluid pH (1.78 mmol/L [>5 mg/dL], base deficit >4 mEq/L, Ca