factors, including infection, GI bleeding, dehydration, hypokalemia, constipation/
ileus, hepatocellular carcinoma, dietary protein overload, CNS active drugs
(narcotics, benzodiazepines, anticholinergics), uremia, hypoxia, hypoglycemia,
and noncompliance with hepatic encephalopathy treatment.
SYMPTOMS/EXAM
■ Insomnia, sleep-wake reversal, personality change, confusion
■ Asterixis
DIFFERENTIAL
Hypoglycemia, hyponatremia, Wernicke-Korsakoff syndrome, trauma, infection
DIAGNOSIS
Diagnosis is clinical. Blood ammonia levels are not always helpful.
TREATMENT
■ Correct precipitating factors and anticipate treatment-related adverse
effects.
■ Oral/NG tube or rectally administered lactulose (adverse effects include
dehydration and hypokalemia); oral neomycin (adverse effects include oto-
toxicity and renal toxicity) or rifaxamin; oral metronidazole (adverse effects
include neuropathy)
■ Zinc, short-term protein restriction, branched-chain amino acid–enriched diet
■ Beware of medications that are hepatically metabolized, eg, benzodi-
azepines such as lorazepam.
Hepatorenal Syndrome
The prognosis is grave. Median survival is 10–14 days. Two-month mortality
is 90%.
DIFFERENTIAL
Prerenal azotemia, acute tubular necrosis, drug-induced disorders (NSAIDs,
antibiotics, radiographic contrast, diuretics), glomerulonephritis, vasculitis.
DIAGNOSIS
Exclude other causes of renal failure. Discontinue diuretics and then perform
a plasma volume expansion trial with 1.5 L IV normal saline or 5% IV albu-
min. If serum creatinine ↓, suspect another diagnosis.
TREATMENT
Identify and treat precipitants. Restrict sodium to <2 g/day if serum Na <125
mEq/L, then restrict fluids to <1.5 L/day. Treat infection; liver transplant is
often required. Renal failure from hepatorenal syndrome reverses with liver
transplant.
Hepatic Abscess
Hepatic abscesses may be pyogenic or amebic. In the United States, most
cases are due to Gram-negative infections as a result of biliary obstruction,
although nearly half have no identifiable cause. Primary amebic liver
abscesses are due to the organism Entamoeba histolytica.
ABDOMINAL AND GASTROINTESTINALEMERGENCIES