And then stage IV is coma, and the coma may be responsive to noxious stimuli or unresponsive to noxious stimuli. Either way, these patients are almost always hospitalized in an intensive care unit.
So the actual grade or the class from these criteria is not critical in private practice, I would say. We use it in research. Certainly, when you have a patient with HE you should document in the chart a little bit what their signs and symptoms are, so that when you see the patient and when others see the patient in following days, they can get an idea of how the patient is doing. Are they doing worse or are they doing better?
Precipitating Factors Supportive care Exclusion. Citation Type. Has PDF. Publication Type. More Filters. International journal of hepatology.
View 1 excerpt, cites methods. View 1 excerpt, cites background. The effects of mild or moderate hepatic impairment on the pharmacokinetics, safety, and tolerability of naloxegol. Journal of clinical pharmacology. Preferential deposition of manganese in the basal ganglia might explain the Parkinsonian symptoms such as tremors seen in some patients with HE. Patients with HE usually have advanced chronic liver disease and thus have many of the physical and laboratory stigmata associated with severe hepatic dysfunction.
Disturbance in the diurnal sleep pattern insomnia and hypersomnia is common, and typically precedes overt neurologic signs. More advanced neurologic features include bradykinesia, asterixis flapping motions of outstretched, dorsiflexed hands. Hyperactive deep tendon reflexes are common; seizures and hallucinations and transient decerebrate posturing may also be seen occasionally. Laboratory abnormalities typically include evidence of hepatic biochemical and synthetic dysfunction, and electrolyte disturbances such as hyponatremia and hypokalemia.
In addition, ammonia is the best characterized neurotoxin that precipitates HE. While ammonia elevations are frequently seen, serial ammonia measurements are not advised, as there is frequently a significant temporal disconnect between blood levels and brain function.
For clinical practice measuring ammonia concentration remains controversial. It may be useful under certain conditions e. The longstanding admonition that arterial ammonia levels are required has been supplanted by studies showing venous ammonia levels perform almost as well. Changes associated with HE are high-amplitude low-frequency waves and triphasic waves.
However, these findings are not specific for HE. When seizure activity must be ruled out, an EEG may be helpful in the initial workup of a patient with cirrhosis and altered mental status. EEG studies are not required to make a confident diagnosis of HE. These studies are not recommended unless there is consideration of alternative or coincidental intracranial disease. The approach to HE comprises exclusion of other causes of encephalopathy, identification of the precipitating cause and a trial of empiric treatment for HE.
A rapid response to this empiric treatment confirms a diagnosis of HE, whereas lack of response within 72 hours indicates that further diagnostic options should be considered. Additional testing is usually not required or helpful. Clinical Scales for Grading HE A number of scales have been devised for the diagnosis of HE; the first of its kind was proposed by Parsonsmith and colleagues in For patients with moderate to severe HE, the Glasgow Coma scale can also be employed.
Stage 0. MHE previously known as subclinical HE. Lack of detectable changes in personality or behavior. Minimal changes in memory, concentration, intellectual function, and coordination. Asterixis is absent. Stage 1. Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria, depression, or irritability.
Mild confusion. Slowing of ability to perform mental tasks. Asterixis can be detected. Stage 2. Lethargy or apathy. Minimal disorientation. Inappropriate behavior. Slurred speech. Obvious asterixis. Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time.
Stage 3. Somnolent but can be aroused, unable to perform mental tasks, gross disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech. Stage 4. Coma with or without response to painful stimuli. However, the terms that limit each stage of the classification are not clearly defined, and the metric characteristics of the stage are unknown.
This staging scale, however, requires further validation. Patients with minimal hepatic encephalopathy MHE have a normal neurological examination; however they may still be symptomatic.
Symptoms relate to disturbances in sleep, memory, attention, concentration and other areas of cognition. A classic sign of HE is a sleep disturbance. Unsatisfactory sleep is associated with higher scores for depression and anxiety, raising the possibility that the effects of chronic disease may underlie the pathogenesis of sleep disturbance.
Defective memory may be a sign of MHE. Patients with MHE have impaired short- and long-term memory. Memory deficit of MHE seems to comprise short-term but not long-term memory impairment. This can be described as an encoding defect, in which memory recall is intact.
Cognitive impairment in MHE mainly affects complex activities involving attention, information processing and psychomotor skills such as driving a car, planning a trip, etc. Patients with MHE had a significant impairment of daily functioning, such as social interaction, alertness, emotional behavior, sleep, work, home management, recreation and pastimes compared with cirrhotic patients who did not have MHE. Treatment with lactulose improved both cognitive functions and health-related quality of life; improvement in the latter was linked to improvement in cognitive function.
Neuropsychological testing is useful methodology for quantifying cognitive impairment due to various forms of encephalopathy, including low-grade or MHE. Neuropsychological tests directly measure cognitive functions that are directly relevant to activities of daily living. They have been applied for the diagnosis of HE for more than 50 years.
The neuropsychological features of MHE point to a disorder of executive functioning, particularly selective attention, visuospatial abilities and fine motor skills. Although these domains are most commonly implicated in MHE, impairments of memory have also been reported.
The attention impairments in MHE are observed on a variety of measures. These include measures of cognitive processing speed involving psychomotor responding, such as the Number Connection tests NCT , block design test BDT ,the Digit Symbol test DST , line drawing test, circle-dotting test, serial-dotting test, figure connection test. Impairments on measures of cognitive processing speed and response inhibition that do not require a motor response have also been reported e.
Fine motor skill impairments have been noted on measures such as the grooved pegboard task, and on line tracing tasks the latter also involve visuospatial abilities. The subjects are asked to connect numbers and letters in alternating manner, that means go from 1-ABC and so on.
Test result is the time needed including error correction time. The BDT is a test of visuospatial and motor skills. The task is to take six to nine blocks that have all white sides, all red sides, and red and white sides and arrange them according to a pattern formed by examiner or shown on a card. This test is scored for speed and accuracy. The DST - the subject is given a series of double boxes with a number given in the upper part.
The task is to draw a symbol pertinent to this number into the lower part of the boxes. Nine fixed pairs of numbers and symbols are given at the top of the test sheet.
Test result is the number of boxes correctly filled within 90 seconds. Pathological test results indicate a deficit in visuo-constructive abilities. The line drawing test is a test of motor speed and accuracy. The patients have to follow the route of this labyrinth without crossing or even touching the borderlines. The number of mistakes and the time needed to go through the labyrinth, both, are test results.
The circle-dotting test is the simplest test of the battery. It is a test of pure motor speed. The subjects are asked to put a dot in each of the circles given on the sheet, after they have prepared by dotting the 20 circles at the top of the sheet, first. Test result is the time needed.
The smartphone application for Stroop test, which is used to evaluate psychomotor speed and cognitive flexibility, could be used to screen for MHE. The application could be administered and interpreted within 5 minutes by medical assistants and could play an important role in the rapid and objective screening for this condition in the clinic.
The Stroop effect is a demonstration of interference in the reaction time of a task. When the name of a color e. The effect is named after John Ridley Stroop who first published the effect in English in The effect has been used to create the psychological test Stroop Test that the application is based on and is widely used in clinical practice and investigations. Current data suggest that patients with MHE tend to have more frequent episodes of overt HE and poorer survival than in those without MHE, and indicate that patients with MHE have a more advanced liver disease.
Some patients with a history of HE may have normal mental status while under treatment. The Child-Pugh score was determined in all patients, and results were compared with the West Haven stage. Exclusion criteria were use of benzodiazepine, beta adrenergic blockers, alcohol, or antiepileptic drugs, or coexistence of depression, dementia, Parkinson's disease, or chronic or acute cerebral vasculopathy.
Results: Of the 77 patients, 44
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