Encephalopathy na Hepatic (Grade 3 da 4 Coma Hanta): Asterxis Flapping Tremor, Hyperammonemia, Cerebral Edema, Lactulose Retention Enema, da Rifaximin¶

Hepatic Encephalopathy (HE) shine mai yuwuwar juyewa, gaggawar neuropsychiatric mai barazanar rai wanda ya haifar da ** matsanancin rashin isashshen hanta da shunting venous portosystemic**, yana faruwa ko dai a cikin Cirrhosis Decompensated / Acute-on-Chronic Liver Failure (ACLF, Encephalopathy) (ALF, Nau'in A Cikakkiyar Rashin Ciwon Hanta, kamar bayan yawan maganin acetaminophen ko ciwon hanta mai saurin kamuwa da cuta/autoimmune). A al'ada, nitrogenous gut gubobi, da farko ** ammonia (\(\ rubutu {NH}_3 / \ rubutu{NH}_4+\)) samar da ƙwayoyin cuta na colonic da ƙananan mucosal glutaminase na hanji, tare da mercaptans, short-sarkar fatty acids, manganese, da GABAergic neurosteroids, tafiya kai tsaye ta hanyar portal hepatocytes. Kashi 85 cikin 100 na ammonia mai shigowa cikin ruwa mara lahani urea (ta hanyar zagayowar urea Ornithine Transcarbamylase [OTC]) da kuma hanta na hanta suna kama sauran kamar glutamine. Lokacin da hawan jini na cirrhotic portal ya tilasta jinin tashar tashar jiragen ruwa don ketare hanta ta hanyar ** tsarin haɗin gwiwa ta hanyar ** (ko ta hanyar ** Transjugular Intrahepatic Portosystemic Shunt [TIPS]) da gazawar hepatocytes sun rasa ƙarfin sake zagayowar urea, wanda ba a cire shi ba ** gaseous ammonia ($ rubutu) zuwa cikin free free astrocytes*. A cikin astrocytes, enzyme ** glutamine synthetase ** ya haɗu da ammonia tare da glutamate don samar da manyan ƙwayoyin intracellular na ** osmotically mai aiki glutamine , jawo ruwa zuwa cikin cytoplasm na astrocyte ( ƙananan astrocyte kumburi a cikin cirrhosis; m cytotoxic cerebral edema, intraniction na kwakwalwa, hypertension a cikin kwakwalwa, hypertension a cikin kwakwalwa, hypertension. Kasawa ) da kuma haifar da gazawar GABAergic/NMDA neurotransmission. Yin amfani da ** West Haven Criteria , Hepatic Encephalopathy yana ci gaba daga Grade 1 (juyawar barci, barcin rana / yawo da dare, rashin hankali) da Grade 2 (rashin hankali, rashin fahimta zuwa lokaci, canjin hali, * fetor hepaticus, da alamar ɓacin rai " dorsiflexed hannaye) zuwa cikin gaggawa na gaggawa guda biyu: ** Daraja na 3 (rashin barci / rashin hankali inda mai haƙuri ya farka kawai don sauti ko rashin jin daɗi, rikicewar rikicewa, rashin daidaituwa, da clonus / hyperreflexia) ** da ** Grade 4 (Hepatic Coma, inda mai haƙuri ya kasance gabaɗaya baya jin zafi, rashin jin daɗi ko rashin jin daɗi, rashin jin daɗi da rashin jin daɗi. sha'awa ko ciwon kwakwalwa yana kusa). Idan duk wani majiyyaci da ke fama da cutar hanta ya sami bacci, rudani, juyewar barcin dare, ko girgizar hannu, kira yankin ku. lambobin gaggawa nan da nan. Hakanan duba jagororin 'yan uwanmu akan cututtukan esophageal rupture, zubar jini na cirrhosis, da ciwon hanta, acetaminophen (paracetamol) wuce gona da iri, rashin hanta shiru, da taga NAC, kuma wernicke encephalopathy da korsakoff ciwo 500 MG IV thiamine.

Babban fifikonku na gaggawa na gaggawa shine ** kare hanyar iska tare da farkon intubation na endotracheal a cikin kowane majiyyaci da ya kai West Haven Grade 3 (mummunan rashin ƙarfi) ko Grade 4 (coma, \(\text{GCS} \ le 8\)), ** kar a taɓa tilasta lactulose na baka a cikin bakin mara lafiyar Grade ¾ mai ƙwanƙwasa mara lafiya. (wanda ke haifar da fatalwar ciwon huhu), ** gudanar da Babban Acidifying Lactulose Retention Enema ($ 300\rubu{mL}$ [\(200\rubu{g}\)] na Lactulose gauraye da \(700\rubu{mL}\) na ruwa ko na al'ada saline [$1,000} ta hanyar \(1,000] a cikin duka m. clamped for 30 to 60 minutes every 4 to 6 hours) ko Nasogastric Lactulose (\)30\text{ to }45\text{mL}$$ to }45\text{mL}$ hourly har sai catharsis, sa'an nan titrated zuwa 2 zuwa 3 taushi acidic stools/rana) PLUS Enteral Rifaximin ($ 550 rubutu sau biyu kullum) L-Orpartine (LOLA) ko Polyethylene Glycol (PEG-3350), da ** a lokaci guda farauta da kuma juyar da 7 classic precipitating triggers ("GIB-SICK": gastrointestinal zub da jini, Kamuwa da cuta / SBP, Benzodiazepines / Opioids, Sodium / Potassium derangements, Creus/Derangements, Creus, da kuma Derangements. Kitchen/Tips shunting)**.

Yi wannan yanzu¶

1. **Kira lambar gaggawa ta gida nan da nan idan mara lafiyar da aka sani ko wanda ake zargi da cutar hanta ya rikice, ya rikice, da wahalar farkawa (Grade 3), ko rashin amsawa (Grade 4). lambobin gaggawa.
2. ** Kiyaye Jirgin Sama Nan da nan a West Haven Grade 3 (Severe Stupor) ko Grade 4 (Coma, \(\text{GCS} \ le 8\)) Kafin Gudanar da Lactulose Enteral.* Kada a taɓa zuba lactulose mai ruwa a cikin bakin majiyyaci mai rauni ko mara hankali. Yi saurin aiwatar da intubation na endotracheal da farko, sannan ku wuce Nasogastric (NG) ko Orogastric (OG) Tube Majinyata ¾ na jinkirin jinkirin ceton rai na ammoniya da gano jinin gastrointestinal).
3. ** Gudanar da Enema 1-Lita Lactulose ($ 300\rubu{mL}$ Lactulose + \(700\rubutu{mL}\) Ruwa/Saline Ake Rike na Minti 30 zuwa 60) don Tarkon Ammoniya Na Gaggawa a Matsayin ¾ Coma ko Ileus.**
4. ** Me yasa Plain Tap-water ko Sabulu-Suds Enemas ya kasa: ** Colonic ammonia trapping yana buƙatar ** luminal acidification ** (saukar da pH na colonic daga $ 7.0 $ zuwa $ <5.0 $ don haka lalatawar ƙwayoyin cuta na lactulose zuwa cikin lactic da acetic acid suna haɓaka haɓakar $ rubutu zuwa iskar gas $ _3 $ ammonium ions) tare da osmotic catharsis.
5. Yadda ake hadawa da sanya Enema na Lactulose: Mix \(300\rubu{mL}\) (\(200\rubutu{gram}\)) na Lactulose Syrup tare da \(700\rubu{mL}\) na ruwa mara kyau ko \(0.9\%\) saline na al'ada* (jimlar girma \(1,000}text\)* Sanya majiyyaci a gefen hagu na decubitus ko matsayi na Trendelenburg, saka bututu mai laushi mai laushi tare da balloon mai riƙewa (ko Foley catheter), saka maganin $ 1,000 a cikin dubura / sigmoid colon, da ** danna catheter na tsawon minti 30 zuwa 60 kafin a sami maganin da ya dace. Maimaita kowane sa'o'i 4 zuwa 6 har sai majiyyaci ya tashi zuwa Grade ½.
6. Haɗa Lactulose tare da Rifaximin ($ 550\rubutu{mg}$ PO/NG Sau Biyu Kullum) ko Yi Amfani da Polyethylene Glycol (PEG-3350, \(4\rubu {Liters}\) ta NG) don Saurin Resolution.
7. Da zarar an tabbatar da bututun NG (ko a farke marasa lafiya na ½), sai a ba da Lactulose \(30\rubutu zuwa }45\rubutu{mL}\) (\(20\rubutu{zuwa}30\rubu{g}\))) kowane awa 1 zuwa 2 har sai hanjin farko ya auku, sannan sai a samar da rubutu zuwa **$15{45} sau hudu a kullum. daidai 2 zuwa 3 stools masu laushi a kowace rana *** (kada a wuce \(> 5\) stools na ruwa / rana, wanda ke haifar da rashin ruwa mai tsanani ** kuma yana damun kwakwalwar kwakwalwa.).
8. Mai gudanarwa Rifaximin \(550\rubutu{mg}\) PO/NG sau biyu a rana (wani maganin rigakafi rifamycin wanda ba zai sha gut ba wanda ke kawar da ƙwayoyin cuta masu haifar da urease).
9. The HELP Randomized Trial Pearl: A asibiti mai tsanani, yana ba da \(4\rubu{lita}\) na Polyethylene Glycol 3350 (GoLYTELY) ta bututun NG sama da awanni 4 yana magance ciwon hanta da sauri a cikin awanni 24 na farko fiye da lactulose kadai.
10. KADA KADA KA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KASA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMA KUMAማይnka bai kasance ba, kuma zaka iya cirewa daga Hanta Hanta saboda Matsayin Jini na Ammoniya "Na al'ada", kuma Koyaushe Daidaita Hypokalemia ($ K+ <3.5\text{mEq/L}$) Nan take.
11. A karkashin ** AASLD da EASL Sharuɗɗan Ayyuka ***, ** Encephalopathy na ciwon hanta a cikin cirrhosis shine ganewar asibiti *: ammonia mai jijiyar cuta tana daidaita da rashin kyau tare da darajar West Haven (kuma an ɗaukaka ta ƙarya idan an bar yawon shakatawa a kan ko kuma ba a sanya bututu mai ruwan hoda/kore a kan kankara kuma a zagaya cikin mintuna 15). Duk da haka, ** cikakkiyar matakin ammonia na plasma na al'ada a cikin mara lafiyar comatose mara kyau yana ba da umarnin neman gaggawar wasu abubuwan da ke haifar da suma (hematoma subdural hematoma, matsayi mara ƙarfi epilepticus, Wernicke encephalopathy, ko overdose na opioid/benzodiazepine).
12. ** Me yasa Hypokalemia ke haifar da Coma Hepatic:** Lokacin da sinadarin potassium ($ K+$) ya faɗi ƙasa da \(3.5\rubu{mEq/L}\) (yawanci daga madauki diuretics), extracellular \(\ rubutu{H}+\) yana canzawa cikin ƙwayoyin tubule na kusanci na koda, yana haifar da ** intracellular renal acidosis da ƙwayoyin ƙwayoyin cuta na ƙwayoyin cuta*** ammoniagenesis** (zubar da sabon \(\ rubutu{NH}_3\) kai tsaye zuwa cikin jijiyar koda), yayin da tsarin alkalosis ke canza cajin \(\ rubutu{NH}_4+\) zuwa \(\rubutu{NH}_3\) gas wanda ya ketare shingen kwakwalwar jini. Maye gurbin potassium da ƙarfi don kiyaye \(K+ \ge 4.0\rubutu{zuwa} }4.5\rubutu{mEq/L}\).
13. ** Rarraba Cirrhotic HE (Nau'in C) daga Ciwon Hanta Mai Ciki (Nau'in A, inda Ammonia \(> 150\rubutu{zuwa }200\rubutu{\mu mol/L}\) Yana haifar da Ciwon Ciwon Kwakwalwa mai Fatal).* osmolytes; Grade ¾ encephalopathy yana haifar da ** m cytotoxic cerebral edema da uncal/tonsillar herniation**. Nan da nan ɗaga kan gadon zuwa \(30\rubutu{digiri}\), infuse ** N-Acetylcysteine ​​(NAC) na cikin jini (NAC)**, da nufin siyar da sinadarin sodium zuwa \(145\rubu{zuwa}155rubu{mEq/L}\) ta amfani da \(3\%\) Hypertonic Saline, da Fara Matsala da wuri ammonia yayin da aka jera don dashen hanta na gaggawa.

Bishiyar yanke shawara: m matakin gaggawa da jujjuyawar Grade 3 & 4 Hepatic Encephalopathy¶

flowchart TD
    A["Mara lafiya tare da Sanannen Ciwon Jiki / Hawan Jiki ko Mummunan Rashin Hanta Yana Gabatarwa Tare da Canjin Halin Haihuwa: Matsayi na 2 (Rashin hankali, Ragewar Jiki, Jigilar Asteris Flapping) KO Daraja na 3 (Somnolent/Stuporous, Rouses Only to Pain/Voice) KO Matsayi na 4 Mai Ragewa, Rashin Haɗuwa"] --> B["Mataki na 1: Nan da nan ABCs, Glucose na Fingerstick, da Tsarin Jirgin Sama: Ba da 500 mg Thiamine IV KAFIN kowane Dextrose; Idan Grade 3 (Mai tsanani Stupor) ko Grade 4 (Coma, GCS <= 8), Yi Nan da nan ENDOTRACHEAL INTUBATION + Place Soft Nasogastric (NG) Tube"]
    B --> C["Mataki na 2: A lokaci guda Ƙarƙashin Ƙarfafa Tsarin / Mimics masu guba DA Audit 7 'GIB-SICK' Masu Haɗawa: 1. STAT Head CT Ba Bambanci (Rule Out Subdural Hematoma); 2. Diagnostic Paracentesis (Dokar fitar da SBP: PMN> = 250 / mm3); 3. Jarabawar CBC/BUN/Rectal (Shardar fitar da jini na GI na Variceal); 4. BMP (Duba K+ <3.5, Na+, Alkalosis, AKI); 5. Al'adun Jini/Fitsari; 6. Rike ALL Diuretics, Benzodiazepines & Opioids"]
    C --> D{"Ƙayyade Nau'in Rashin Rashin Hanta: Nau'in C (Decompensated Cirrhosis / ACLF) vs. Nau'in A (Rashin Rashin Hanta)"}
    D -->|TYPE C: Decompensated Cirrhosis / Portal Hypertension| E{"Shin Mara lafiya Zai Iya Samun Magungunan NG / Baki Lafiyayyan, ko Akwai Tsananin Ileus / Matsayin Marasa Lafiya na 3-4?"}
    E -->|Grade 3-4 Without NG Access OR Severe Paralytic Ileus / Abdominal Distension| F["PROTOCOL RECTAL ENEMA: Saka 300 ml (200 g) Lactulose + 700 mL Ruwa / Saline (1,000 ml Total) ta hanyar Rectal Balloon Catheter; Matsa na tsawon mintuna 30 zuwa 60 don Aiwatar da Gudun Dama; Maimaita kowane 4 zuwa 6 hours"]
    E -->|Intubated with Verified NG Tube OR Awake Grade 2 Patient| G["ENTERAL AMMONIA-PURGING PROTOCOL: 1. Lactulose 30 zuwa 45 ml PO/NG Kowane Sa'o'i 1-2 Har sai Farko na Farko, Sa'an nan Titrate (15-45 ml TID-QID) zuwa 2-3 Soft Stools / Day (OR 4 LE PEG-3350 over 4h); 2. Ƙara Rifaximin 550 mg PO/NG BID; 3. Ƙara IV L-Ornithine L-Aspartate (LOLA 20-40 g / day) idan Refractory"]
    F --> H["Mataki na 3: Tsanani Yi Magance Takamaiman Hazo Mai Tafiya: 1. Daidaitaccen Hypokalemia (Ajiye K+>= 4.0-4.5 mEq/L don Dakatar da Renal Ammoniagenesis); 2. IV Volume Resuscitation / Albumin don Diuretic AKI; 3. IV Ceftriaxone idan SBP ko Variceal Bleed; 4. IV Flumazenil (0.2 MG) Gwaji idan Benzodiazepine Trigger ake zargi"]
    G --> H
    D -->|TYPE A: Fulminant Acute Liver Failure (INR >= 1.5 + Encephalopathy Without Prior Cirrhosis, Ammonia > 150 umol/L)| I["MAGANGANUN RASHIN RASHIN HANTA CEREBRAL EDEMA PROTOCOL (HIGH HERNIATION RISK): 1. Intubate & Elevate Head 30°; 2. Fara IV N-Acetylcysteine ​​(NAC); 3. Sanya 3% Hypertonic Saline (Manufa Serum Na + 145-155 mEq/L) + Mannitol Bolus don ICP Spikes; 4. Fara Ci gaba da Ci gaba da Maganin Maye gurbin Renal (CRRT) don Share Ammoniya; 5. Jerin dashen Hanta na gaggawa"]

Pathophysiology: yadda ammonia, glutamine synthetase, da hypokalemic alkalosis ke haifar da kumburin astrocyte kuma me yasa Asterxis ya ɓace a cikin Coma na 4¶

1. Astrocyte "Trojan Horse" Hasashen (Albrecht & Norenberg)¶

A cikin mutane masu lafiya, ammonia portal vein da aka samo daga ** urea na kwayan cuta na hanji ** da ** ƙananan hanji enterocyte glutaminase ** ana canza su ta hanyar hepatocytes na periportal zuwa urea ta hanyar zagayowar urea ** Krebs-Henseleit urea . A cikin cirrhosis ko gazawar hanta, tsarin ammonia na jijiya yana tashi sau 3 zuwa 10. 1. ** Ketare Katangar Kwakwalwa na Jini: A cikin jini, ammonia yana wanzuwa a cikin ma'auni mai dogaro da pH tsakanin cajin ** Ammonium ions (\(\ rubutu{NH}_4+\), \(98\%\) a pH \(7.40\))** kuma ba a caja Ammonia gas (\(\text{NH}_4+\) \(\text{pK}_a \kimanin 9.15\)): $\(\rubutu{NH}_4+ \rightleftharpoons \rubutu{NH}_3\rubutu{(lipophilic gas)} + \rubutu{H}+\)$ ** Alkalosis na narkewa ko numfashi (yawanci yana haifar da diuretics, amai, ko hyperventilation) yana canza wannan ma'auni zuwa dama, ninka ko ninka juzu'in da ba a cajin \(\ rubutu{NH}_3\) gas , wanda ke yaduwa ba tare da wahala ba a cikin shingen jini-kwakwalwa zuwa cikin astrocytes kawai cikin kwakwalwar mutum. synthetase). 2. ** Kumburi na Osmotic + Mitochondrial Poisoning ("Dokin Trojan"): A cikin cytoplasm na astrocyte, ** glutamine synthetase ** ya haɗu da $ rubutu {NH}_3 $ tare da glutamate don haɗawa ** Glutamine : - ** Tasirin Osmotic: Maɗaukakin ƙwayar intracellular na glutamine yana aiki azaman osmolyte wanda ke jan ruwa ta hanyar ** Aquaporin-4 tashoshi ** a cikin matakan ƙafar astrocyte, haifar da ** Ciwon ƙwayar cuta na II astrocytosis ** (a cikin cirrhosis na yau da kullun, astrocytes a cikin wani ɓangare na ramawa ta hanyar fitar da myo-inositocute * babu wani lokaci a cikin Fayil A. don fitar da myo-inositol, wanda ke haifar da ** cike da edema mai cike da ƙwayar cuta da ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta ** duk lokacin da ammoniya jijiya ta wuce \(150\rubutu{zuwa }200\rubutu{ \mu mol/L}\)). - ** The "Trojan Horse" Mitochondrial Collapse: ** Sabon hada glutamine yana hawa zuwa cikin mitochondria astrocyte, inda phosphate-activated glutaminase ya raba shi daidai da mayar da hankali ** intra-mitochondrial ammonia ($ rubutu {NH} _3 $), da kuma bude T permeability. nau'in oxygen / nitrogen mai amsawa, lalata ATP, da haɓaka ** GABA-A sautin mai karɓa ** (ta hanyar benzodiazepine-kamar neurosteroids kamar su allopregnanolone).

HOW LACTULOSE & RIFAXIMIN TRAP AMMONIA IN THE COLON (LUMINAL ACIDIFICATION)
===========================================================================
  [Colonic Lumen (Normal pH = 7.0)]            [Portal Venous Bloodstream]
  Urease-Producing Gut Bacteria                Uncharged Ammonia Gas (NH3)
  (Klebsiella, Proteus, E. coli)               freely crosses colonic wall
  break down protein/blood/urea                into Portal Vein --> Shunts
  into diffusible NH3 gas.                     past cirrhotic liver to Brain.
               |
  =============X===========================================================
  THERAPEUTIC INTERVENTION 1: RIFAXIMIN (550 mg BID)
  Kills colonic urease-producing bacteria & downregulates gut glutaminase.
  =========================================================================
  THERAPEUTIC INTERVENTION 2: LACTULOSE (Oral/NG or 300 mL Retention Enema)
  Non-absorbable disaccharide (Galactose-Fructose) reaches cecum/colon intact
  --> Colonic saccharolytic bacteria ferment Lactulose into LACTIC & ACETIC ACID
  --> Drops Colonic Luminal pH from 7.0 down to < 5.0.
  =========================================================================
               |
               v
  [ACIDIFIED COLONIC LUMEN (pH < 5.0): THE ION TRAP]
   Diffusible NH3 Gas + H+  ====>  Charged Ammonium Ion (NH4+)
   - Because NH4+ carries a positive electrical charge, it CANNOT cross the
     colonic mucosa into the blood (AND blood NH3 diffuses *into* the acidic
     colon to become trapped as NH4+.).
   - Osmotic catharsis purges trapped NH4+ out in 2 to 3 soft stools/day.
===========================================================================

2. Menene "Asterixis" (Flapping Tremor), kuma Me yasa Yake Bacewa Lokacin da Majinyacin ya Rage daga Sashin 3 zuwa Coma na 4?¶

• Yadda ake Kashe Asterixis a Gefen Bed: Tambayi mara lafiya ya miqa hannayensa biyu a tsaye a gabansu, dorsiflex hannayensu baya ("kamar dakatar da zirga-zirga"), yada yatsunsu daban, sannan su rufe idanunsu na tsawon dakika 30. (A cikin majiyyaci na aji 3 mai bacci wanda ba zai iya ɗaga hannuwansa sama ba, a hankali dorsiflex wuyan wuyan majiyyaci ko tambayar su su matse yatsun mai binciken biyu ko su fitar da harshensu).
• Abin da ke faruwa (Myoclonus mara kyau): Ba kamar parkinsonian ko girgiza mai mahimmanci (wanda shine rhythmic muscle * contraction *), ** asterxis shine "myoclonus mara kyau"**: kwatsam, involuntary ** $ 50 rubutu {- zuwa } 200\text{-millisecond duka biyu ( $ MG) aiki *** lalacewa ta hanyar rashin aiki na rayuwa na ** diencephalic-reticular motor hade hanyoyin ** wanda ke kula da sautin bayan gida. Nauyi a taƙaice yana sauke wuyan hannu gaba, sannan wani juyi mai jujjuyawa ya biyo baya har zuwa matsayi mai tsawo, yana haifar da yanayin rashin daidaituwa, na gefe " girgizar fuka-fukin tsuntsu."
• ** Tarko Mai Muhimmanci na asibiti:** Asterxis yana buƙatar ** sautin cortical postural na son rai** ya wanzu. Saboda haka, asterxis ya shahara a ** West Haven Grades 2 da farkon Grade 3 , amma gaba ɗaya bace lokacin da majiyyaci ya nutse cikin zurfin Grade 3 ko Grade 4 Coma. Kada kayi tunanin mara lafiya mai rauni yana inganta saboda kawai girgizar da suke yi ta tsaya; duba ko sun ci gaba zuwa Grade 4 coma (inda bangarorin biyu ** clonus, hyperreflexia, Babinski ãyõyi, ko decerebrate posting ** maye gurbin asteris).

Matsayin asibiti: Ma'auni na West Haven Haɗe tare da Rarraba ISHEN da Sikelin Coma na Glasgow¶

Abubuwan Haɗaɗɗen Hannu guda 7 na Fasali na 3 & 4 Hepatic Encephalopathy ("GIB-SICK") da Yadda ake Juya Kowa.¶

A cikin ** sama da kashi 80 zuwa 90 na marasa lafiya masu fama da cutar cirrhosis**, wani mummunan lamari na Grade 3 ko Grade 4 Hepatic Encephalopathy yana kunna ta wani takamaiman magani mai jujjuyawa. ** Yin maganin ammonia tare da lactulose yayin da aka rasa abin da ke haifar da shi (kamar Kwayoyin cuta na Kwayoyin cuta ko kuma zubar da jini) yana ɗaukar yawan mace-mace ***:

Asibitin mataki-mataki & ICU Pharmacotherapy Protocol¶

Lambobin gaggawa na yanki da jagororin asibiti¶

• Amurka da Kanada: Kiran kira 911 ga duk wani majiyyaci da ke da cirrhosis ko gazawar hanta da ke tasowa da rudani, tashin hankali, asterixis, ko zub da jini na ciki. Gudanarwa yana biye da ** Ƙungiyar Amirka don Nazarin Cututtukan Hanta (AASLD) Jagoran Ayyuka akan Ciwon Hanta a Ciwon Hanta na Ciwon Hanta ** da ** AASLD Matsayin Takarda akan Mummunan Rashin Hanta **.
• United Kingdom: Kiran kira 999 ko halartar Sashen Gaggawa na NHS. Ma'aikatan asibiti suna bin ** Societyungiyar Gastroenterology na Burtaniya (BSG) / BASL Decompensated Cirrhosis Care Bundle ** da ** NICE Guidelines (NG50 / TA337)**, wanda ke ba da izinin bugun ascitic tap a cikin sa'o'i 6, faɗakarwa nunawa, lactulose / rifaximin far, da IV Pabrinex (thiamine).
• ** Tarayyar Turai:** Kiran Kira 112. Clinicians follow the European Association for the Study of the Liver (EASL) Clinical Practice Guidelines on the Management of Hepatic Encephalopathy (2022 Update), endorsing West Haven/ISHEN grading, lactulose retention enemas in Grade ¾, rifaximin, and IV L-Ornithine L-Aspartate (LOLA).
• ** Ostiraliya da New Zealand:** Dial 000 a Ostiraliya ko 111 a New Zealand kuma ku bi Gastroenterological Society of Australia (GESA) cirrhosis da ƙa'idodin gazawar hanta.

Tambayoyin da ake yawan yi¶

Me yasa ba za ku taɓa hana furotin daga abincin mara lafiyar da ke murmurewa daga ciwon Hanta ba?¶

Shekaru da yawa, tsofaffin litattafan likitanci sun yi kuskure sun gaya wa marasa lafiya da ke da cirrhosis su ci "abinci maras gina jiki" don guje wa yin ammonia. Jagororin ilimin hanta na zamani (AASLD da EASL) sun kawar da hana gina jiki gaba ɗaya. Me yasa? A cikin mara lafiya da cirrhosis wanda hanta ba zai iya sake lalata ammonia ba, tsokar kwarangwal ta zama sashin jiki na lamba-daya don cire ammonia daga jini (filayen tsoka suna amfani da glutamine synthetase don kama ammoniya jini). Ƙuntata furotin na abinci yana haifar da ɓarnawar tsoka mai tsanani (sarcopenia), wanda ke lalata majinyacin madadin ammonia-clears muscle mass kuma yana sa su Hepatic Encephalopathy ya fi muni da yawa. Da zarar majiyyaci ya farka daga mummunan yanayin rashin lafiya, dole ne su cinye gram 1.2 zuwa 1.5 na furotin a kowace kilogiram na nauyin jiki a kowace rana, suna jaddada kayan lambu, kiwo, da sunadaran amino acid (BCAA) da aka rarraba a cikin ƙananan abinci akai-akai PLUS abincin abincin furotin mai girma na dare.

Ta yaya Lactulose Enema ke aiki lokacin da mara lafiya mai rauni ba zai iya haɗiye ba, kuma me yasa ruwan famfo na fili bai isa ba?¶

A cikin Grade 3 ko Grade 4 Hepatic Encephalopathy, majiyyaci ya yi wauta sosai ko kuma ya yi kasala don ya hadiye lami lafiya, kuma inna mai shanyayyen na iya rage ruwan da ake bayarwa ta bututun ciki. Sanya enema mai riƙewa da aka yi da 300 ml na Lactulose syrup gauraye da 700 ml na ruwa (jimlar lita 1) kai tsaye a cikin hanji da murƙushe catheter na dubura na tsawon mintuna 30 zuwa 60 yana ba da lactulose kai tsaye zuwa ƙwayoyin ƙwayoyin cuta inda kashi 70 na gut ammonia aka yi. Ba kamar ƙoshin ruwa na famfo ba (wanda kawai ke wanke stool da inji), ƙwayoyin ƙwayoyin cuta suna saurin haɓaka lactulose cikin lactic acid, suna sauke pH a cikin hanjin ƙasa 5.0. Wannan acid yana juya gas ammonia (NH3) zuwa ions ammonium ions (NH4+), kuma a zahiri yana fitar da ammonia daga cikin tasoshin jini zuwa cikin stool mai acidic don fitar da shi lokacin da aka zubar da enema.

Me yasa ba da yawan yawa Lactulose zai iya haifar da rashin lafiyar mara lafiya?¶

Manufar maganin lactulose bayan tsarkakewar farko shine tsananin laushi 2 zuwa 3, motsin hanji na acidic kowace rana, ba zawowar ruwa guda 10 kowace rana ba. Saboda lactulose wani laxative osmotic ne wanda ke fitar da ruwa mai tsafta daga cikin jini zuwa cikin hanji, bada yawan adadin lactulose a kowane lokaci yana haifar da asarar ruwa mai yawa a cikin stool. A cikin sa'o'i 24 zuwa 48, mai haƙuri yana tasowa hypernatremia mai tsanani (sodium jini yana tashi sama da 150 zuwa 160 mEq / L) da hypovolemic m koda rauni. Duka mai tsanani hypernatremia da dehydration suna haifar da nasu na rayuwa encephalopathy da kuma dakatar da kodan daga excreting urea da ammonia, sa majiyyaci nutse zurfi cikin wani suma yayin da likitoci kuskure ci gaba da oda mafi lactulose.

Me yasa karancin potassium (Hypokalemia) ke haifar da ciwon hanta mai tsanani a cikin marasa lafiya da ke shan kwayoyin ruwa (Furosemide)?¶

Marasa lafiya masu fama da cirrhosis da cikin ruwa mai ruwa (ascites) akai-akai suna shan diuretics kamar furosemide (Lasix), wanda ke haifar da kodan ta zubar da potassium a cikin fitsari. Lokacin da potassium na jini ya faɗi ƙasa da 3.5mEq/L, potassium yana barin cikin ƙwayoyin tubule na koda kuma ions hydrogen (acid) ya koma ciki don ɗaukar wurinsa. Ganin cewa cikin su ya zama acidic, ƙwayoyin tubule na koda na kusa suna kunna haɓakar ammonia mai ƙarfi (renal ammoniagenesis) don ɗaukar acid ɗin fitsari, suna fitar da ammonia mai yawa kai tsaye zuwa cikin jijiyoyin koda. A lokaci guda, jinin da ke cikin cell ya zama alkaline (alkalosis na rayuwa), wanda ke canza ammonium mai aminci (NH4+) zuwa iskar ammonia mai guba mai guba (NH3) wanda ke ratsa cikin kwakwalwa kai tsaye. Kawai maido da potassium na jini sama da 4.0 zuwa 4.5mEq/L yana kashe masana'antar ammonia na koda.

Tushen da jagorar hukuma¶

• ** Ƙungiyar Tarayyar Turai don Nazarin Hanta (EASL): ** * Sharuɗɗa na Ayyukan Clinical na EASL akan Gudanar da Ciwon Ciwon Hanta (2022 Sabuntawa, Jarida na Hepatology): West Haven / ISHEN Grading, Ƙirar Ƙarfafawa, Lactulose Enemas, Rifaximin, da LOLA *.
• ** Ƙungiyar Amirka don Nazarin Cututtukan Hanta (AASLD) da EASL Jagoran Ayyukan Haɗin gwiwa (Vilstrup H, Amodio P, Bajaj J et al., * Hepatology*):** * Encephalopathy na Hepatic a cikin Ciwon Hanta na yau da kullum: Jagorar Ayyuka ta AASLD da EASL *.
• ** New England Journal of Medicine (NEJM, Bass NM et al. & Wijdicks EFM): *** Rifaximin Jiyya a cikin Hepatic Encephalopathy; Nazari na Ayyukan Asibiti na Cutar Cutar Hanta*.
• JAMA Magungunan Ciki (Taimako Randomized Trial, Rahimi RS, Singal AG et al.): Lactulose vs. Polyethylene Glycol 3350-Electrolyte Magani don Maganin Hepatic Encephalopathy Overt.
• ** Ƙungiyar Biritaniya na Gastroenterology (BSG) da Ƙungiyar Biritaniya don Nazarin Hanta (BASL):** * Bundle Kula da Cirrhosis mai Ragewa: Gudanar da Gaggawa na Sa'o'i 24 na Farko*.

Jagora masu alaƙa¶

• Rushewar Esophageal varices, zubar jini na cirrhosis, da ciwon hanta
• Acetaminophen (paracetamol) wuce gona da iri, gazawar hanta shiru, da taga NAC
• Wernicke encephalopathy da Korsakoff ciwo: 500 MG IV thiamine kafin dextrose
• Tsananin hyponatremia, maye gurɓataccen ruwa, da ƙwanƙwasa edema
• Lambobin gaggawa ta ƙasa