EXAMINATION OF A PATIENT WITH HEPATIC ENCEPHALOPATHY/ALTERED CONSCIOUSNESS LEVEL

1. EXAMINATION OF A PATIENT WITH HEPATIC ENCEPHALOPATHY/ALTERED CONSCIOUSNESS LEVEL Dr. AminulHaq

2. Major Differential Diagnosis of Altered Consciousness (groups & examples) • Metabolic Diseases; Hypoglycemia,DKA, Non ketotic Hyperglycemic coma, CKD (uremia) Hepatic encephalopathy, CO2 narcosis ,Wilson’s Disease, Wernicke’s encephalopathy • Infections ; cerebral malaria, acute pyogenic meningitis, encephalitis (viral). • Vacular accidents; haemorrhagic/ischemic stroke,SAH,chronic subdural/ Extra duralhaematoma • Drugs toxicity/ overdosage ; sedatives ,drugs used by pocket pickers,opium,alcohol . • Tumours i.e. ICSOL • Head injury/ Trauma

3. Types of HE • Type A (=acute) describes hepatic encephalopathy associated with acute liver failure typically associated with cerebral oedema • Type B (=bypass) is caused by portal-systemic shunting without associated intrinsic liver disease • Type C (=cirrhosis) occurs in patients with cirrhosis -  episodic,persistent and minimal encephalopathy

4. Assessing the Severity of HE • Two types of scoring system is available which can be applied for the assessment of the severity of the condition; • West Haven Criteria • Glassgow Coma scale

5. Grading of Hepatic Encephlopathy(West Haven Criteria) • Grade 0. Lack of detectable changes in personality or behavior. Asterixis absent. • Grade 1. Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria or depression. Asterixis can be detected. • Grade 2. Lethargy or apathy. Disorientation. Inappropriate behavior. Slurred speech. Obvious asterixis. • Grade 3. Gross disorientation. Bizarre behavior. Semistupor to stupor. Asterixis generally absent. • Grade 4. Coma.

6. Level of consciousness in Glassgow Coma Scale; to obtain the score, ocular,verbal and motor responses are summed up. The best is 15 the poorest 3, anything >12 is severe encephalopathy

7. Clinical Examination • Salam/ Greeting • Introduction • Consent • If the patient is conscious and able to communicate,otherwise ask the assistance of the attendant of the patient.

8. Evoluation of the High Mental Functions • Speech; the disturbance of speech is the earliest sign of hepatic encephlopathy. Going through the greetings and consent , it might has been assessed to a sufficient degree, eg slurred, dysarthric etc etc • Sleep; reversal of the sleep pattern is again an earlier sign of the onset of HE. Ascertain it by asking the sleep pattern. Patients are sleepy at the day while awake at night, if under the effect of encephalopathy.

9. Evoluation of the High Mental Functions (cont…) • Orientation; Three parameters should be assessed. • Time; orientation to the time is 1st to be disturbed. Patient lose recognition of time • Place/space • Person

10. Evoluation of the High Mental Functions (cont…) • Memory; 3 types of memory should be assessed’ • Past • Recent • Recall • Arithematics/mathematics; simple mathematical questions are asked from the patient accrding to his educational status eg 100-7= ? And so on

11. Evoluation of the High Mental Functions (cont…) • Figure tracking/ tracing; figures 1-30 are written in haphazard way on a piece of paper, and the patient is asked to join them serially. A normal individual would take 15-30 seconds to join them, however a pt. under the effect of HE would take longer. This test can not be excecised in an illitrate patient. • Constructional apraxia; make simple shapes on a piece of paper like a circle, triangular, star in front of the patient and ask him/her to copy. A patient who is having problem in mentation would make deformed shapes .

12. Examination of the eyes; • Jaundice,anemia,KF rings, • Size and reaction of the pupils (constricted pupils in opium toxicity and pontinehaemorrhage. • Fundoscopy; papilloedema in ICSOL, High intracranial pressure, hypertensive encephalopathy, diabetic retinopathy

13. Examination of the mouth • Peculiar smell of foetorhepaticus, diabetic ketoacidosis,organophosphate poisoning. There is no need to take the nose near the mouth of the patient, it could be appreciated as such ,if any. • Hyperpigmentation of the buccal mucosa in addisson’s disease coma • Face ,neck and chest;spider nevi , gynaecomastia ,axillary hair

14. Examination of Hands; clubbing, lukonychia, palmer erythema, Duputren’s contracture, bruises, petechiae, spider nevi • Flapping tremors; ask the patient to outstretch the hands and arms by hyper-extending the fingers, wrists,elbows and shoulders if possible. The flapping tremors would be observed if patient has grade II or grade III encephalopathy, It may also be called Bird’s wing movement or Traffic police sign.It is usually not there in grade I and can not be elicited in grade IV encephalopathy.

15. Examination of the abdomen; • Caput medusae • Ascites; shape, umbilicus, shifting dullness, fluid thrill. • Splenomegaly • Liver ,small shrunkened/ Enlarged eg HCC, liver span • Hernialorifices,pubic hair, testicular atrophy ( males)

16. Examination of the feet and legs; pitting oedema,bruises, petechiae

17. Quick neurological assessment • Muscle tone • Power • Reflexes • Plantar reflex . It is bilaterally up in metabolic comas usually, but in case of focal neurogical disturbance it may be unilaterally up going on the affected side if due to upper Motor Neurone lesion.

18. Finishing the examination • Recover and reposition the patient to the initial comfortable position. While doing so, try to recapitulate the positive and relevant negative findings in your mind and prepare for the 1st question of examiner which usually sounds like “OK, beta! What do you think? What did you find? • Always thank the patient and give a good wish to the patient (e.g Allah de kha ka) even if you are really in hurry. • Face to the examiner and look him/her in eyes, in a confident way.

19. Mechanism of Hepatic Flapping Tremor • The patient should be able to percieve tbe command to outstretch the hands and maintain it. • The sensory cortex relays the command to motor cortex . Then the motor cortex commands the effector organs to obey the command to outstretch the hands and cerebellum is directed to maintain the outstretched hands. • As the relay syatem between the cerebellum and cerebrum is under the toxic effect of neurotoxins the cerebellum fails to maintain the coordination and there is a fall , the repetition of this process results in the phenomenon called Flapping Tremors.