JOURNAL READING

BY
MELYANA , DR

RESOURCE PERSON
DR ETRA ADRIADNO SP.PD

SMF PENYAKIT DALAM RS TNI AL DR. MINTOHARDJO

DEPARTEMEN KARDIOLOGI DAN KEDOKTERAN VASKULAR
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
2017
 OUT
OUTLINE
LINE

This review Focused

on
 Definition
Hepatic
Hepaticencephalopathy
encephalopathyisisaabrain
braindysfunction
dysfunction
caused
caused
by
byliver
liverinsufficiency
insufficiencyand/or
and/orPSS;
PSS;ititmanifests
manifestsas
as
aawide
wide
spectrum
spectrumof
ofneurological
neurologicalor
orpsychiatric
psychiatric
abnormalities
abnormalities
ranging
rangingfrom
fromsubclinical
subclinicalalterations
alterationsto
tocoma.
coma.
 Prevalence of Overt Hepatic
Ensefalophaty
10%-14% at the time of diagnosis of cirrhosis

16%-21% in those with decompensated cirrhosis

10%-50% in patients with transjugular intrahepatic

portosystemic shunt (TIPS)

The risk for the first of OHE is 5%-25% within 5 years

after cirrhosis diagnosis,
Subjects with a previous OHE were found to have a 40%
cumulative risk of recurring OHE at 1 year,
Subjects with recurrent OHE have a 40% cumulative risk of
another recurrence within 6 months, despite lactulose
treatment.
 Classification
Classification

Type A resulting from ALF

Type B resulting predominantly

According to the
from portosystemic bypass
underlying disease or shunting

Type C resulting from cirrhosis

 Classification
Classification
alterations of tests
exploring psychomotor
speed/executive
Minimal functions
Neurophysiological
According alterations without
clinical evidence of
to the mental change
severity Gr
ad
of the e
I Trivial lack of
awareness
disease Euphoria or anxiety
Shortened attention
span
Impairment of addition
or subtraction
Altered sleep rhythm
 Classification
Classification
Lethargy or apathy
Disorientation for time
Obvious personality
change
Inappropriate behavior
Dyspraxia
According Asterixis
III
to the a de
Gr
severity Somnolence to
of the semistupor
Responsive to stimuli
disease Confused
Gross disorientation
Grade IV Bizarre behavior

Grade IV Coma
 Classification
Classification

Episodic HE

According to its time Recurrent HE

course

Persistent HE
 Classification
Classification

Nonprecipitated

Precipitated
According to the existence
of precipitating factors
Differential
DifferentialDiagnosis
Diagnosis
 Recommendation
Recommendation
Hepatic encephalopathy should be classified
according to

the
HAPUS
type of underlying disease,
SLIDENYA KRN
severity of manifestations, ADA DI SLIDE 12

time course

precipitating factors

A diagnostic workup is required, considering

other disorders that can alter brain function and
the type of underlying disease

Classification
severity of manifestations of Hepatic
Encephalopat
Time course
y

Precipitating Factor
 Diagnosis
Diagnosisand
andTesting
Testing
Testing for MHE and CHE
Minimal hepatic encephalopathy and CHE is defined as the presence of test-
dependent or clinical signs of brain dysfunction in patients with CLD who are
not disoriented or display asterixis.

Usefulness of MHE and CHE test

Prognostic of OHE development
indicate poor quality of life and reduced socioeconomic potential
Predict recurrence of HE before stopping HE drug
 Diagnosis
Diagnosisand
andTesting
Testing
indicate poor quality
Prognostic of OHE of life and reduced
development socioeconomic
potential

Usefulness of MHE and

CHE test

Predict recurrence of
HE before stopping
HE drug
 Diagnosis
Diagnosisand
andTesting
Testing
Several MHE and CHE test
Portosystemic encephalopathy (PSE)
syndrome test The PSE-Syndrom-Test is a
battery consisting of five paper-
The Critical Flicker Frequency (CFF) and-pencil tasks, including
test Number Connection Tests A and
The Continuous Reaction Time (CRT) B, a coding test (Digit Symbol
Test) similar to the Digit Symbol
test
subtest of the Wechsler scales,
The Inhibitory Control Test (ICT) the Serial Dotting Test and the
Line Drawing Test
The Stroop test
The SCAN Test
Electroencephalography examination
 Diagnosis
Diagnosisand
andTesting
Testing
Several MHE and CHE test
Portosystemic encephalopathy (PSE)
syndrome test
The Critical Flicker Frequency (CFF)
test Computer asissted test,
determines the frequency at
The Continuous Reaction Time (CRT) which a flickering light becomes
test continuous or 'fused'.
The Inhibitory Control Test (ICT)
The Stroop test
The SCAN Test
Electroencephalography examination
 Diagnosis
Diagnosisand
andTesting
Testing

Laboratory testing blood

ammonia level
Useful for
Excluding HE
Test the efficacy of HE drug
Increased blood ammonia alone
does not add any diagnostic,
staging, or prognostic value for
HE in patients with CLD. A
normal value calls for diagnostic
reevaluation
 Treatment
Treatment
Minimal hepatic
encephalopathy
and CHE can be
treated in special
circumstances
(e.g., impairment only OHE is routinely
in driving skills,
work treated.
performance,
quality of life, or
cognitive
complaints)
 Recommendation
Recommendationfor
for
Treatment
Treatment
General Recommendation
OHE type C include the episode of OHE (whether spontaneous or
precipitated) should be actively treated (GRADE II-2, A, 1).
Secondary prophylaxis after an episode for overt HE is
recommended (GRADE I, A, 1).
Primary prophylaxis for prevention of episodes of OHE is not
required, except in patients with cirrhosis with a known high risk
to develop HE (GRADE II-3, C, 2).
Recurrent intractable OHE, together with liver failure, is an
indication for LT (GRADE I).
 Recommendation
Recommendationfor
forTreatment
Treatment

Specific Approach to OHE Treatment

A four-pronged approach to management of HE is recommended
Initiation of care for patients with altered consciousness
Alternative causes of altered mental status should be sought and
treated.
Identification of precipitating factors and their correction
Commencement of empirical HE treatment
 Recommendation
Recommendationfor
forTreatment
Treatment
Identify and treat precipitating factors for HE (GRADE II-2, A, 1).
Lactulose is the first choice for treatment of episodic OHE (GRADE II-1, B, 1).

Lactulose is recommended
for prevention of recurrent
episodes of HE after the
initial episode
 Recommendation
Recommendationfor
forTreatment
Treatment
Rifaximin is an effective add-on therapy to lactulose for prevention of OHE
recurrence (GRADEI, A, 1).

Rifaximin as an add-on to lactulose

is recommended for prevention of
recurrent episodes of HE after the
second episode

Rifaximin
 Routine prophylactic
therapy (lactulose or
rifaximin) is not
recommended for the
prevention of post TIPS HE

Rifaximin
 Recommendation
Recommendationfor
forTreatment
Treatment

Oral BCAAs can be used as an alternative or additional agent to

treat patients nonresponsive to conventional therapy (GRADE I,
B, 2).
IV LOLA can be used as an alternative or additional agent to
treat patients nonresponsive to conventional therapy (GRADE I,
B, 2).
Neomycin is an alternative choice for treatment of OHE (GRADE
II-1, B, 2).
Metronidazole is an alternative choice for treatment of OHE
 Lactulose is recommended for prevention of recurrent episodes of HE
after the initial episode
Rifaximin as an add-on to lactulose is recommended for prevention of
recurrent episodes of HE after the second episode
Routine prophylactic therapy (lactulose or rifaximin) is not recommended
for the prevention of post TIPS HE
Under circumstances where the precipitating factors have been well
controlled (i.e., infections) or liver function or nutritional status
improved, prophylactic therapy may be discontinued
 Treatment of MHE and CHE is not routinely recommended apart from a case-by-
case basis
Daily energy intakes should be 35-40 kcal/kg ideal body weight
Daily protein intake should be 1.2-1.5 g/kg/ day
Small meals or liquid nutritional supplements evenly distributed throughout the day
and a latenight snack should be offered
Oral BCAA supplementation may allow recommended nitrogen intake to be
achieved and maintained in patients intolerant of dietary protein