非货币性资产HepaticEncephalopathy
Hepatic encephalopathy (HE) is a clinical syndrome of reversible neuropsychiatric impairment of varying verity. There is continuing controversy about its exact pathogenesis, but gut-derived toxins, including ammonia, are clearly implicated. Features of HE may be subclinical (covert) or clinically evident (overt) and include a wide range of neuropsychiatric signs and symptoms. The prevalence of HE varies depending on the clinical subtype and the verity of liver dia, with cumulative prevalence rates of up to 80% for covert HE and 30% to 40% for overt HE in patients with cirrhosis. Although the West Haven criteria are widely ud for grading the verity of HE (Table 8), current guidelines recommend using three additional axes to classify HE bad on the etiology, time cour, and prence or abnce of a precipitating factor (Table 9).
Covert HE is considered preclinical and encompass minimal HE (features of HE that are only diagnod by specialized neuropsychiatric testing) and grade 1 HE as per West Haven criteria. In contrast, overt HE is characterized by clinical findings of HE ranging from subtle
订的组词
changes in orientation and prence of asterixis to hepatic coma (grades 2 to 4 per West Haven criteria).女人自卫
Specialized testing is necessary to establish a diagnosis of covert HE. The psychometric hepatic encephalopathy score is regarded as the gold standard, but additional asssments include the number connection test, computerized tests such as the inhibitory control test, the cognitive drug rearch battery, and electroencephalogram. The tests, however, are not applicable in routine clinical practice and usually require consultation with a specialist. A smartphone application that evaluates psychomotor speed and cognitive alertness has been developed and validated as a point-of-care screening tool for covert HE: EncephalApp Stroop.
设备状态
The diagnosis of overt HE is clinical and supported by the prence of a wide spectrum of global neurologic deficits. Severe HE, grades 3 and 4 West Haven criteria, should prompt attention to airway protection, and endotracheal intubation ought to be considered.
口占一绝的意思
There are no laboratory markers that can be accurately ud to diagno overt HE. Blood ammonia levels lack nsitivity and specificity and correlate poorly with the verity of encephalopathy. Furthermore, a normal ammonia level does not preclude the prence of HE, and venous ammonia levels are influenced by veral other factors including phlebotomy technique and handling of the blood specimen. Efforts must be directed at identifying potential precipitating factors for HE, such as compliance with treatment of HE, new medications, gastrointestinal bleeding, AKI, electrolyte imbalances, and infections.
Management of covert and overt HE is centered on the u of nonabsorbable disaccharides and antibiotics. Lactulo (Enulo) is the most widely ud nonabsorbable disaccharide. Although the exact mechanism responsible for its therapeutic efficacy is stillunclear, this agent is degraded by colonic microbiota to short-chain organic acids, resulting in acidification of the intestinal lumen and incread conversion of absorbable ammonia to nonabsorbable ammonium. The starting dosage for lactulo depends on the acuity and verity of HE but must be titrated to achieve two to four soft bowel movements per day. For patients who cannot tolerate oral administratio
n (i.e., high risk for aspiration or coma), lactulo can be administered as an enema (300 mL of lactulo solution 10 g/15 mL in 700 mL of saline or water). The cathartic effects of nonabsorbable disaccharides may result in profu diarrhea, dehydration, and hypernatremia平安中学. Rifaximin (Xifaxan) is a broad-spectrum antibiotic with activity against gram-positive, gram-negative, and anaerobic enteric bacteria that can be ud in addition to lactulo for prevention of recurrent episodes of HE. Data from clinical trials show marked reductions in HE-related hospitalization and significant improvements in health-related quality of life in patients treated with a combination of lactulo and rifaximin without an incread rate of adver events.
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