Professional Documents
Culture Documents
PAPDI Purwokerto
Purwokerto
2016
Hepatic Encephalopathy
in Chronic Liver Disease
• Minimal
• Grade I-IV
Classification
• Recurrent HE
• Persistent HE
Classification
• 4. existence of precipitating
factors :
• Nonprecipitated
• Precipitated
Precipitating Factors
• GI bleeding
• Infection
• SBP
• Paracentesis >>>>
• Hypokalemia
• Constipation
Source: Bajaj JS, et al. Hepatology. 2012;55:1164-71.
Epidemiology
NH3
Glutamine NH3
NH3
Urea Glutamine
Glutamine
NH3 NH4+ Urea
Feces Urine
Ammonia intoxication hypothesis
phenylalanine → phenylethanolamine
tyrosine →
octopamine
BCAA/AAA
Insulin↑, glucagon ↑ ↑, insulin/glucagon ↓
Increased production of aromatic AA and
increased uptake and utilization of branch
chain AA
Inhibiting the production of normal
neurotransmitters
Promoting the production of false
neurotransmitters
Increased production of 5-
hydroxytryptophan(5-HT)
The gamma-aminobutyric acid
hypothesis GABA
Inhibitory neurotransmitters
Decarboxylase
↓
Glutamate →GABA
Number Connection Test
• Used for > 50 years to assess Number Connection Test
Patient’s Name
mental performance Date
Completion Time
51 to 80 I - II
seconds
81 – 120 II - III
seconds
Forced III
termination
Source: Weissenborn et al. J Hepatology May 2011
Rifaximin
• Arginin : 7,3 g