eMedicine Patient UK Alabama Gastroenterology Grading encephalopathy Consciousness (level of awareness), speech, motor, neurological (tone, plantar reex

x & eyes). Grade 1. Slightly confused but they are alert. Inverted sleep cycle. Motor is pretty good. However, should not let them drive a car because beginning to get their apraxia. Speech and neurological exam are normal. Grade 2. Difcult to arouse. Speech is slurred. Motor is impaired (difculty buttoning their shirt, difculty drawing 5 point star). Getting their asterixis. Grade 3. Somnolent but rousable. Disoriented to time and place. Marked confusion. Occasional ts of rage (never give benzodiazepine because will make encephalopathy worse!) Speech is incomprehensible. Motor is severely impaired. Asterixis absent. Tone is hypertonic and reexes are very brisk. May or may not have clones. Grade 4. Coma. No speech. Very hypertonic ("very twitchy"). Get clonus. Finally, if there is ICP then there is risk of morbidity and mortality. So if they have positive babinski and unequal pupils then that is a very serious sign of ICP. "Patient is in stage 2 encephalopathy. How do you manage?" Know the causes and investigate Drugs. Like acute alcoholic intoxication. Then you have to decide whether presentation is alcoholic withdrawal or hepatic encephalopathy. Benzodiazepines is big cause! Don't give opiates. Infection Upper GI bleed, constipation & high protein load. Dehydration Acidosis, hyponatremia, hypoxia, electrolyte shift Investigate & Management Septic screen Electrolytes etc. Give empiric antibiotics Give oxygen DRE in the A&E. And if there is stool give them a phosphate enema. Ensure 2 bowel motions a day. Put them on docusate or lactulose. If bowels don't open then write down for phosphate enemas. Then write "not for benzodiazepines. Not for opiates." "Has belly full of uid. What are you going to do?" Diagnostic aspirate and send for albumin, WCC and differential for SBP, glucose, pH, microscopy and culture. E. coli and enterococci. Send for cytology and amylase especially for alcohol patients. PMN < 250, i.e. there's no SBP. How are you going to treat her? First step in the treatment of ascites in liver disease is to salt restriction down to about 80 mmol/day. Daily weight gain should be no more than 0.5 kg to 1 kg per day. If renal impairment then no more than 0.5 kg per day.

Note that creatinine and urea levels are unreliable because these patients are not producing protein! If still gaining weight despite salt restriction then give spiranolactone to turn off RAA system. Start with single dose daily, before they get out of bed in the morning. Start 50, 100, 200, 250, 300. And if still not losing it then add furosemide. Give furosemide hour before spiranolactone so that more salt goes to the distal tubules.

"So losing weight and you're happy. But then creatinine starts to rise; you're putting them into hepatorenal syndrome. What do you do?" Stop all nephrotoxic drugs. Do a uid challenge test and creatinine drops. Still has ascites, what do you do? That's when you uid restrict them. Still not winning the game. What do you do? Consider a TIPS or recurrent large volume paracentesis. Patient UK.