Hepatic Encephalopathy

Total confusion

Step 1: View clinicals

A 55-year-old man presents with sudden onset hematemesis. He has vomited bright red blood 6 times during the past 3 hours, with about half a cup in volume (~125 mL) each time. He has also become increasingly confused since the onset of symptoms. There are no previous episodes of hematemesis, abdominal pain, anorexia or recent weight loss, but he has passed black, tarry stools for a week now. He was diagnosed with Hepatitis C ten years ago, which was believed to be secondary to a blood transfusion following an automobile accident. He defaulted on follow-up soon afterwards, and is currently not on any medications. He stopped drinking around the same time, and even before this, only drank socially. The remainder of his history is unremarkable. On arrival, he is tachycardic at 110 bpm with a blood pressure of 90/50 mmHg, requiring immediate fluid resuscitation. Subsequently, a nasogastric tube is inserted. A blood glucose level and serum electrolyte assay are found to be within normal ranges.

Step 2: Order all relevant investigations

Complete blood count

WBC: 7,000/mm3 (3,500-10,500/mm3) Hb: 5 g/dL (13.5-17.5 g/dL) Hct: 18% (38.8-50%) Plt: 80,000/mm3 (150,000-450,000/mm3)

Liver profile

AST: 70 U/L (8 - 48) ALT: 65 U/L (7 - 55) Total bilirubin: 6 mg/dL (0.3-1.9) Direct bilirubin: 3 mg/dL (0-0.3) Albumin: 2 g/dL (3.4-5.4) INR: 1.6 (0.9-1.1)

Ultrasound abdomen

Abdominal ultrasonography reveals a shrunken, cirrhotic liver with heterogeneous echotexture, an irregular edge and surface nodularity. No focal hepatic lesions are present. The portal vein is dilated to 15.5mm (fasting), while the splenic vein is dilated to 13.5 mm, with multiple collaterals. There is splenomegaly obscuring the left kidney, with a span of 20 cm. Abdominal free fluid is present, showing moderate ascites.

Upper gastrointestinal (UGI) endoscopy

The upper GI endoscopy reveals three columns of grade III-IV esophageal varices with signs of recent bleeding, along with severe portal hypertensive gastropathy (PHG). No fundal varices are seen. Therapeutic esophageal band ligation is performed during the procedure, with good hometostasis.

Step 3: Select appropriate management

Packed RBC Transfusion

Score: ★★☆