Hepatic encephalopathy

TheCommuter, BSN, RN · Aug 7, 2010

My mother had hepatic encephalopathy back in 2002 because her serum ammonia levels were rising. Her ammonia levels were rising because her liver was failing. Her liver was failing because she had received a transfusion with HCV+ blood products during a surgical procedure in the early 1980s. She received a transfusion that had been tainted with HCV because blood banks were not routinely screening donors and blood products prior to the middle 1980s.

Meanwhile, my mother was in a coma for nine days before she received the gift of life, a liver transplantation. Soon after receiving the new liver, she emerged from the coma and the confusion slowly eased up. More than eight years has elapsed since this took place, and my mother has other chronic health problems, but her transplant team regards the procedure as a success.

Here's a tidbit. Although my mother was never on this particular medication, Lactulose (Enulose) helps with hepatic encephalopathy by keeping the ammonia levels from rising dangerously high. Lactulose binds to the ammonia in a person's body and the excess is excreted with feces.

totally_nuts · Aug 7, 2010

My son developed hepatic encephalopathy while have chemotherapy for leukaemia.

He had a rare reaction to asparaginase (one of the chemo drugs) that caused his ammonia levels to rise to a toxic level. He was slipping in and out of a coma and the doctors weren't sure to start with why it was happening. The doctors were aware that this could happen but had never actually seen a case of it.

We were told he would probably need dialysis and that eventually he may need a liver transplant if they couldn't get it under control quickly. He had a NG tube inserted and was given treatment through that but I can't remember now exactly what it was. He was not allowed to eat anything that contained protein - do you have any idea how hard that is???!!! He was encouraged to drink coke, because it is full of empty calories and now he is a coke addict!!

Eventually his levels reduced and we didn't have to go through dialysis. There is still a chance that as he ages he still need a liver transplant and if the leukaemia relapses, they can't use some of the chemo drugs to treat it.

Hope that helps you.

Cheers

Chris

jesskidding, LPN · Aug 7, 2010

Hello! Both of my husbands parents have HCV. His mother passed away in 2005 from HCV. His dad found her in a coma after he got home from work one day. The coma was due to toxic levels of ammonia. She never recovered and was on life support in the ICU for two days. After she died, my father in law stopped being responsible with his meds including the Lactulose. He had many "episodes" due to the increased ammonia levels including two seizures. He is now taking meds and the Lactulose regularly and seems to be doing well.

nminodob · Aug 7, 2010

I work on a TBI unit that has a lot of other neuro pts, including those with cirrhosis (alcoholic and otherwise) and HCV. Any of our pts with ESLD (end stage liver disease) are vulnerable to hepatic encephalopathy, which requires them to take lactulose to reduce ammonia levels through their stools, as other posters have mentioned. If memory serves me, we draw blood samples for ammonia levels in light green top specimen tubes, and they are placed on ice and sent immediately to the lab. Since ammonia is produced when bacteria in the gut metabolize protein, some MDs will also order an antibiotic to reduce the amount of intestinal bacteria, although apparently this has become less common as a treatment.

From a nursing perspective, having a disoriented, encephalopathic pt. with a huge belly from ascites who is stooling frequently can be a nightmare! Of course, they are also at risk for skin breakdown, especially so if they are also edematous. And those that are "walkie-talkies" are also at risk for falls since they may run to the bathroom with an urgent need to relieve themselves.

Hope this helps!

BackfromRetirement · Aug 7, 2010

When I worked at the VA hospital back in the 80's this was a common diagnosis. I remember one pt that was ordered lactulose enemas q2h. The smell of the ammonia diarrhea is very distinct. Although most delirium cleared up in a few days, there were a few who remained in delirium for weeks. Major behavior/safety issues. It was always a 2 person assist for any care given. Now days there are better methods of addressing the aspects of HE.

SweetLemon · Aug 7, 2010

Thanks for all the great replies.... and I am so sorry to hear some of the more personal stories of family members who had to deal with HE it has to be so much harder when you are caring for your own loved ones!:redbeathe

Something interesting I found with Alcohol induced encephalopathy benzodiazepines can often times make things worse (still working on figuring out the ins and outs of why... I will post it when I find it). But with that said when we get patients who are detoxing for alcohol and we are trying to avoid DTs what is often times the first medication we put them on... Lorazepam (benzodiazepine). I currently have a patient who I think may be suffering from some alcohol induced encephalopathy who is having lots of disorientation, confusion, and full blown hallucinations that he has trouble distinguishing from reality. We have seen this patient many times in the last few months. Each time he comes in his BAL is through the roof and to prevent DTs or seizures we quickly get him on frequent doses of ativan.... wondering if this may be causing some of his current disorientation. The doc ordered an ammonia level thurs and I will be really interested to see what it comes back at when I go back monday.... So say that is the case if we started putting him on barbiturates when he came in for alcohol withdrawal instead of benzos would it have the same effect for the HE?

porterwoman · Aug 7, 2010

Benzos just simply stick around longer in a liver failure pt than in a pt with a normal liver. Gotta do what you gotta do; just important to be aware that the benzos can build up & suddenly a wild encephalopathic pt becomes a barely breathing barely rousable pt. Ooops!

Something I've seen lately that may be interesting to your unofficial study group--in addition to (or sometimes instead of) lactulose, I'm seeing pts receive rifaxamin to treat hepatic encephalopathy, with some good results. Rifaxamin is normally used to treat e. coli diarrhea. That may be the antibiotic you are referring to, nminodob.

Lactulose is more effective via NG tube, so that's generally the preferred way to give it. Unfortunately, if the pt has esophageal varices, the NG may not be an option--although, unless they've been recently banded, you supposedly can safely put down an NGT. Rectal just doesn't do as well, but, again, you do what you gotta do, or what you CAN do.

Good for you for trying to learn more! Best of luck.

RaziRN · Aug 8, 2010

Benzos just simply stick around longer in a liver failure pt than in a pt with a normal liver. Gotta do what you gotta do; just important to be aware that the benzos can build up & suddenly a wild encephalopathic pt becomes a barely breathing barely rousable pt. Ooops!
Something I've seen lately that may be interesting to your unofficial study group--in addition to (or sometimes instead of) lactulose, I'm seeing pts receive rifaxamin to treat hepatic encephalopathy, with some good results. Rifaxamin is normally used to treat e. coli diarrhea. That may be the antibiotic you are referring to, nminodob.
Lactulose is more effective via NG tube, so that's generally the preferred way to give it. Unfortunately, if the pt has esophageal varices, the NG may not be an option--although, unless they've been recently banded, you supposedly can safely put down an NGT. Rectal just doesn't do as well, but, again, you do what you gotta do, or what you CAN do.
Good for you for trying to learn more! Best of luck.

Just wanted to thank you for the clarification. I had a pt. this week with HE and he had been getting lactulose enemas daily and lactulose 60 ml PO and was still lethargic and only A&O to self. He was very child-like in his interactions with others. Well he had been ordered rifamaxin (sp?) and I couldn't figure out what it was for. Your post was very informative. And to the one of the other posters, yes...lactulose poo has a very distinct odor and definitely puts even your more oriented pt.s at a fall risk. Incidentally, I had four pt.s out of 7 who were alcoholics...lots of Ativan going around. My future HE pt.s for sure.