Patients with end stage liver disease can develop a metabolic encephalopathy. The severity of the encephalopathy can be graded by clinical signs and symptoms.
|
Stage of Encephalopathy |
Motor Findings |
|
subclinical |
impaired motor performance detectable on standardized or bedside tests |
|
I |
fine tremor slowed coordination incoordination asterixis apraxia |
|
II |
asterixis dysarthria primitive reflexes (suck and snout) ataxic paratonia hypoactive reflexes |
|
III |
hyperreflexia extensor plantar response incontinence myoclonus hyperventilation |
|
IV |
decerebrate posturing brisk oculocephalic reflexes response to painful stimuli early may progress to flaccidity and absence of response to stimuli |
|
Stage of Encephalopathy |
Mental Findings |
|
subclinical |
no changes on routine examination may show impaired work performance may show impaired driving ability |
|
I |
mild confusion apathy agitation anxiety euphoria restlessness sleep disorder impaired handwriting forgetfulness irritability |
|
II |
drowsiness lethargy disoriented to time inappropriate behavior slow responses |
|
III |
somnolent but rousable marked confusion incomprehensible speech disoriented to place aggressive behavior |
|
IV |
coma (nonrousable) |
|
Clinical Finding |
Description |
|
asterixis |
abnormal, irregular, distal involuntary jerking movement, best shown with hands pronated and arms outstretched with fingers extended |
|
dysarthria |
defect in phonation as well as resonation |
|
suck reflex: |
sucking movement of the mouth elicited by touching an object to an infant's lips |
|
ataxic paratonia |
ataxia = failure of muscular coordination; paratonia = disorder of tone or tension |
|
myoclonus |
sudden nonrhythmic, nonpatterned coarse jerks affecting resting groups of muscles |
|
decerebrate posturing |
bilateral extensor posture with (1) adduction and internal rotation of the shoulders, (2) extension of the elbows and wrists, (3) extension of the lower extremities |
|
decorticate posturing |
(1) adduction of the shoulders, (2) bilateral flexion at the elbows and wrists, (3) extension of the lower extremities |
|
oculocephalic reflexes |
also known as the doll's eye phenomenon; when supranuclear influences on the oculomotor nerve are removed, the eyes seem to maintain fixation on a point in the distance when the head is passively turned laterally from side to side. |
|
Stage |
Electroencephalographic (EEG) Findings |
|
normal |
none |
|
subclinical |
none |
|
I |
triphasic waves |
|
II |
triphasic waves |
|
III |
triphasic waves |
|
IV |
delta activity |
where:
• Triphasic waves show 5 cycles per second.
Differential diagnosis:
(1) head trauma
(2) cerebrovascular accident
(3) infection (meningitis, sepsis, encephalitis, etc.)
(4) psychiatric states
(5) nonhepatic metabolic disorders
(6) drug-induced states
(7) Wernicke-Korsakoff syndrome
Specialty: Neurology, Gastroenterology
