Hepatic coma

By | 15th May 2012

 

It is a neuropsychiatric syndrome secondary to liver disease characterized by unconsciousness.

 

Etiology:

 

  1. Cirrhosis of liver
  2. Acute fulminant hepatitis
  3. Biliary cirrhosis
  4. Surgical portal venous shunt
  5. Portal hypertension

 

Precipitating factors

 

  • High protein intake
  • Alcohol
  • Constipation
  • Infection
  • Fluid electrolyte imbalance
  • GI bleeding

 

Pathophysiology

Hepatic coma occurs when blood bypass the liver through collateral circulation .as the liver is the main detoxification organ of toxic substance, so toxic substances directly reach the brain. These substances include ammonia, free fatty acids, and false neurotransmitters. These toxic substances are responsible for hepatic encephalopathy.

 

Clinical features:

 

Symptoms

Initially there is irritability, confusion, disorientation, slow slurred speech.

Nausea, vomiting, weakness, hiccups, drowsiness.

Hyperventilation and pyrexia.

 

Signs

Fetor hepaticus (musty sour smell).

Coarse flapping tremors

Hyperreflexia

Bilateral extensor planter response.

Jaundice may be present.

 

Investigation

Blood complete picture will show increased ESR, WBC and decreased RBC.

Liver biochemistry will show prolonged prothrombin time, increased SGOT, SGPT and bilirubin.

 

Blood urea will show the renal status.

Blood glucose can exclude the hypoglycemia.

 

Differential diagnosis.

 

Dural and subdural hemorrhage

Drunkenness

Wilson’s disease

Hypoglycemia

Diabetes ketoacidosis

Primary psychiatric disorders

 

Management

Immediate.

 

Hospitalized the patient

Pass nasogastric tube and insert cannula to maintain I.V line

Identify the precipitating factors and remove them

Catheterize the patient.

Liquid protein free diet.

Give purgatives with enemas.

IV 20 % glucose.

Correct any electrolyte imbalance.

Oral neomycin 1-4 g daily?

Correct ay infection.

 

Long term

Increase the protein intake slowly

Avoid constipation

Avoid precipitating factors

Avoid sedatives and hypnotics

Use flumazanil (benzodiazepine antagonist)