Grading
- Grade 0: no encephalopathy
- Normal consciousness, personality, neurological examination, and electroencephalogram
- Grade 1: changes in behaviour with minimal change in level of consciousness
- Restless, sleep disturbed, irritable/agitated, termor, impaired handwriting, 5 cps waves on EEG
- Grade 2: gross disorientation, drowsiness, possibly asterixis, inappropriate behaviour
- Lethargic, time-disoriented, inappropriate, asterixis, ataxia, slow triphasic waves on EEG
- Grade 3: marked confusion, incoherent speech, sleeping most of the time but arousable to vocal stimulus
- Somnolent, stuporous, place-disoriented, hyperactive reflexes, rigidity, slower waves on EEG
- Grade 4: comatose, unresponsive to pain, decorticate or decerebrate posturing
- Unrousable coma, no personality/behvaiour, decerebrate, slow 2-3 cps delta activity on EEG
Investigations
- In general, discourage measuring serum ammonia
Management
Acute
Chronic prophylaxis
- Lactulose
- Add-on: rifaximin
- Reassess adherence
- Assess for medications contributing to encephalopathy
