A case of Grade III Hepatic Encephalopathy

A case of Grade III Hepatic Encephalopathy

Hepatic encephalopathy (HE) comprises of neuropsychiatric abnormalities occurring in patients with significant liver disease and/or major portosystemic shunting of blood. Patients with advanced liver disease are more likely to exhibit HE, but they are also more prone to present with multiple simultaneous causes of encephalopathy.  Here, we describe a case of Hepatic Encephalopathy Grade III secondary to decompensated Chronic Liver Disease (Alcohol Induced)  with Portal Hypertension.

47 years old male patient, chronic alcoholic for over 22 years presented to the Emergency Department with 12 hours history of drowsiness  associated with difficulty waking up, slurring of speech, confusion, disorientation. There was also history of yellowish discoloration of skin,  swelling of limbs, abdominal distension and passage of dark colored urine. Patient had not passed stool for last 2 days.  There was no history of loss of consciousness, abnormal body movement, urine or stool incontinence. No history of epistaxis, vomiting, black discoloration of stool, shortness of breath, chest pain, palpitation, orthopnea. Patient had undergone band ligation for Grade II Esophageal varices secondary to Chronic Liver Disease 8 months back.

At the time of presentation, patient was ill looking, drowsy and grossly disoriented. Glasgow Coma Scale was E4 V4 M6 (14/15). Physical findings include icterus, bilateral pedal pitting edema and mildly distended abdomen. Vitals were stable.

Patient was admitted in Medical ICU and was managed conservatively with   IV fluids , Thiamine supplementation , Vitamin K , Lactulose, Antibiotics and Inj. Albumin.

Complete Blood Count, Renal Function Tests , Urine Routine & Microscopic Examination, Serum Calcium  were within normal limits. Ascitic tapping was planned but no fluid was visualized on USG.  Liver function tests include elevated Bilirubin i.e Total and Direct Bilirubin were 6.8 mg/dl and 4.4 mg/dl respectively. SGPT and SGOT were 150IU/L  and 218 IU/L  respectively. Albumin level before correction was 1.9 gm/dl which later improved to 3.1 gm/dl. Blood Culture showed no growth over 72 hours.

Patient mental status improved gradually during the course of treatment. Patient was discharged on 5th day of admission and was asked to follow up after one week.