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Management of hepatic encephalopathy

Diagnosis
·       Known or suspected CLD presenting with altered sensorium
·       ALF
·       No neurological cause on examination or imaging

Investigations        
·      Neurological examination to rule out focal cause
·      Hemogram RFT,LFT,INR, Sugar, ECG
·      Arterial NH: >200ug/dl is associated with cerebral herniation , >75ug/dl is associated with Hepatic encephalopathy
·      USG abdomen
·      Brain imaging in relevant cases
Severity assessment
·      West Haven Grades
Minimal HE : Normal examination , subtle changes in working /driving
                       Abnormal visual perception , Psychometric  or number test  
Grade !:Personality changes , attention deficits , depressed state or irritability
Grade II: Change in sleep -wake cycle , lethargy , mood changes Flap+
Grade  III: Altered level of consciousness , disorientation , O/E Muscular rigidity, clonus, hyporeflexia 
Grade IV: Stupor and coma  O/E : Oculocephalic reflex, unresponsiveness to noxious stimuli
Management
·      Grade I/II HE
·      Identify cerebral edema, avoid sedation  
·      Syp. Lactulose  (15-30ml) 6hrly OR
Lactulose bowel wash (200ml in 800ml of water)
·      Tab.Rifaximin 400mg 8hrly
·      Grade III/IV HE
        Continue above , elevate head of bed 300 May need Intubation
·      ICP monitoring
 Treatment of cerebral edema
·      Goal -ICP<20MMhG
·      IV Mannitol 20%, 100ml TDS if there is no renal failure
·      Correct Hyponatremia  145-155mmol/L

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