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Hepatic Encephalopathie (Grade 3 and 4 Liver Coma): Asterixis Flapping Tremor, Hyperammonemia, Cerebral Edema, Lactulose Retention Enema, and Rifaximin

Emergency numbers differ by country. This page uses 911, the number for the United States and Canada. Many other countries use 112, 999, or another number. Find the number for your country.

Disama dia mu tshifu (HE) ndisama dia mu lungenyi didi mua kupingana, didi mua kunyanga muoyo didi difumina ku dipanga dia tshifu dikole ne dinyanguka dia mijilu ya mu tshifu, didi dienzeka mu Cirrhose Decompensated / Acute-on-Chronic Liver Failure (A, CCL) anyi mu Disama dia tshiadi (ALF, Disama dia tshiadi dia mushindu wa A, bu mudi panyima pa dikuatshika dia acetaminophen anyi disama dia tshiadi dia tshimpitshimpi dia virus/auto-immune). Pa tshibidilu, bintu bia mu mala bidi ne azote, nangananga ammoniaque (\(\text{NH}_3 / \text{NH}_4+\)) bipatuka kudi bactérie ya mu tshifu ne glutaminase wa mu mala makese, pamue ne mercaptans, aside ya mafuta a mu tshitupa tshipi, manganese, ne GABAergique, bidi bibuela buludiludi mu tshiibi tshia mijilu tshifu, mudi periportal hepatocytes umbusha 85 pa lukama ya ammoniake udi ubuela mu urea udi kayi ne njiwu mu mayi (ku diambuluisha dia Ornithine Transcarbamylase [OTC] urea cycle) ne perivenous hepatocytes ikuata tshitupa tshikuabu bu glutamine. Padi disama dia cirrhose portal hypertension dienzeja mashi a mu tshibuelelu bua kupita mu tshifu kupitshila ku portosystemic collateral shunts (anyi ku diambuluisha dia Transjugular Intrahepatic Portosystemic Shunt [TIPS]) ne hepatocytes idi kayiyi yenza mudimu idi ijimija bukole bua urea-cycle, gaseous ammoniaque ($kzwxh:0001* mu mashi adi kaayi toxique adi apitshila mu mashi tshibuelelu tshia tshianana mu astrocyteya mu buongo. Munda mua astrocytes, enzyme glutamine synthetase udi usangisha ammonia ne glutamate bua kuenza bungi bunene bua glutamine udi wenza mudimu mu selile, udikoka mayi mu cytoplasme wa astrocyte (divulangana dia astcyte dia mushinga mu cirrhose; cytotoxique cytotoxique wa cytotoxique wa edebral, hypertension wa buongo, ne hernicration mu dipanga dia tshifu) ne diza dia GABAergic/NMDA dipanga dia dituma dia mijilu. Ku diambuluisha dia West Han Criteria*, Hepatic Encehalopathy udi uya kumpala kumbukila ku Grade 1** (dishintuluka dia tulu-dibika, dilala dia munya/diendakana butuku, dipanga dia ntema) ne Grade 2 (dipanga dia ntema, dipanga dia lungenyi lua dîbadishintuluka dia bumuntu, etor hepaticus*, ne **tshimanyinu tshia tshifu tshia **"disama anyi disama dia bilateral" bianza bimane ku nyima) mu bilumbu bibidi bia lukasa bia luondapu: **Mulongo wa 3 (dilala/dipanga dia lungei mudi mubedi ujuka anu ku dîyi anyi dia malu mabi, dipanga dia lungenyi, dipanga dia lungenyi, ne clonus/hyperreflexia) ne Mulongo wa 4 (Coma wa mu tshifu, mudi mubedi kayi witaba nansha kakese kanyinganyinga, udi umvua bibi anyi udi umvua bibi decerebrate posturing, ne aspiration anyi herniation cerebrale udi pabuipi). Shi mubedi udi na disama dia tshiadi udi ubanga kulala tulu, udi upanga lungenyi, udi kayi ulala tulu mu munya ne butuku, anyi udi wenda unyunguluka tshianza, ubikile muaba uudi musombele nomba ya tshimpitshimpi diakamue. Tangila kabidi mikanda yetu ya bana betu pa dibutuka dia mishipa ya mu tshifu, dipatuka dia mashi mu tshifu, ne disama dia tshiadi, acetaminophen (paracetamol) mupita bungi, disama dia tshiadi didi kadiyi diumvuika, ne NAC window, ne wernicke encephalopathy ne korsakoff syndrome 500 mg IV thiamine.

Tshia kumpala tshiudi ne bua kuenza mu tshimpitshimpi ntshia kulama njila wa luya ne dibueja dia endotracheal kumpala kua dîba kudi mubedi yonso udi ufika ku West Haven Grade 3 (severe stupor) anyi Grade 4 (coma, \(\text{GCS} \le 8\)), kuenzeji lactulose oral mukana mua mubedi udi ne poros 34 tube anyi verified nasogastric tube (udi ukebesha disama dia tshiadi tshia lufu), fila High-Volume Acidifying Lactulose Retention Enema (\(300\text{ mL}\) [\(200\text{ g}\)] wa Lactulose musambakaja ne \(700\text m{\)} anyi wa mayi a saline [\(100\00, mL}\) total] mubueja ku diambuluisha dia tshintu tshia kuela mu tshifu tshidibu basuike munkatshi mua minite 30 too ne ku 60 kunyima kua mêba 4 anyi 6) anyi Nasogastric Lactulose (\(30\text{ too ne ku }45\text{ mL}\) ku dîba too ne ku catharsis, pashishe tshiteka ku 2 anyi 3 soft acidic stools/PLUS (\(550\text{ mg}\) misangu ibidi ku dituku) ne Intravenous L-Ornithine L-Aspartate (LOLA) anyi Polyethylene Glycol (PEG-3350), ne musangu umue kukeba ne kupingaja malu 7 adi asaka bantu ku dienza malu ("GIB-SICK": Gastrointinal Infection, BP/S Benzodiazepines/Opioids, Sodium/Potassium derangements, Ileus/Constipation, Creatinine/Dehydration from diuretics, and Kitchen/TIPS shunting).

Enza nunku mpindieu

  1. Bikila nimero ya tshimpitshimpi ya muaba unudi pikala mubedi udi ne disama dia tshiadi dimanyike anyi didibu bela meji ne: udi ne disama dia tshiadi udi mubungame, mupangile tshia kuenza, udi ne lutatu lua kujuka (mu tshitupa tshia 3), anyi kayi wandamuna (mu tshitupa tshia 4). Ela 911 mu États-Unis ne mu Canada, 999 mu Royaume-Uni, 112 mu Union européenne mujima, 0000 mu Australie, anyi mulombodi wetu wa buloba bujima nomba ya tshimpitshimpi.
  2. Lama njila wa lupepele diakamue mu West Haven tshitupa tshia 3 (tshikole tshia dipanga dia lungenyi) anyi tshitupa tshia 4 (Coma, \(\text{GCS} \le 8\)) kumpala kua kufila Enteral Lactulose. Babedi ba mu tshitupa tshia 3 anyi 4 tshia disama dia tshiadi tshia mu tshifu mbajimije bukole bua kukuba tshiadi ne tshifu. Kuena ne bua kuela lactulose mukana mua mubedi udi kayi ne makanda anyi udi kayi ne lungenyi to. Enza kumpala endotracheal intubation wa lukasa, pashishe upitshishe Nasogastric (NG) anyi Orogastric (OG) Tube (manya ne: esophageal varices ki mbualu budi kabuyi mua kukumbana bua kuenza mudimu ne tube wa NG mutoke udi ne mafuta mimpe ne NG to; tube mu mubedi wa Grade ¾ mubueja mu tshiadi udi ulengulula diumusha dia amoniak udi usungila muoyo ne dimanya dia mashi adi apatuka mu tshifu).
  3. Kufila 1-Litre Lactulose Retention Enema (\(300\text{ mL}\) Lactulose + \(700\text{ mL}\) Water/Saline Retained for 30 to 60 Minutes) bua Immediate Colonic Ammonia Trapping mu Grade ¾ Coma anyi Ileus.
  4. Bua tshinyi enemas ya mayi a mu pompi anyi ya nsabanga itu ipanga: Dikuata dia ammoniaque mu tshifu didi dilomba acidification luminal (kupuekesha pH wa mu tshifu kumbukila ku \(7.0\) too ne ku \(< 5.0\) nunku dikosolola dia bactérie dia lactulose mu lactic ne acide acétique didi dienza bua se \(\text {N\)3} udi kayi mua kuangata gaz \(\text{NH}_4+\) ammonium ions) pamue ne osmotic catharsis.
  5. Mushindu wa kusangila ne kuela Lactulose Retention Enema: Sangila \(300\text{ mL}\) (\(200\text{ grams}\)) wa Lactulose Syrup ne \(700\text{ mL}\) wa mayi a sterile anyi \(0.9\%\) wa saline wa pa tshibidilu (total volume \(100\t mL}\)). Teka mubedi mu tshitupa tshia ku dia bakaji tshia decubitus anyi Trendelenburg, wela tshiamu tshia mu tshifu tshidi ne tshiamu tshia kulama natshi (anyi Foley catheter), wela tshiamu tshia \(1,000\text{ mL}\) mu tshifu/tshiamu tshia sigmoid, ne kanga tshiamu tshia catheter munkatshi mua minite 30 too ne ku 60 bua kufika ku tshiadi tshia dia balume udi wenza bua lumen ikale ne aside kumpala kua kumupatula. Enza kabidi kunyima kua meba 4 to ne ku 6 too ne padi mubedi ujuka mu kalasa ka ½.
  6. Sangila Lactulose ne Rifaximin (\(550\text{ mg}\) PO/NG misangu ibidi ku dituku) anyi Enza mudimu ne Polyethylene Glycol (PEG-3350, \(4\text{ Liters}\) via NG) bua kujikija lukasa.
  7. Padibu bajadike ne: NG tube (anyi mu babedi ba mu kalasa ka ½ badi batabale), ufila Lactulose \(30\text{ to }45\text{ mL}\) (\(20\text{ to }30\text{ g}\)) kunyima kua mêba 1 anyi 2 too ne padi dipatuka dia mala dia kumpala dienzeka, pashishe ** to {text{15\(\text{ mL}\) }45\text{ mL}$ misangu ibidi anyi inayi ku dituku bua kupatula menemene 2 anyi 3 ya tuishi tutekete ku dituku** (kuena ne bua kupitshisha tuishi tua mâyi too ne ku \(> 5\)/dituku to, bidi bifikisha ku dipanga dia mâyi mu mubidi ne bidi mua kunyangakaja disama dia mutu.).
  8. Udi mua kufila Rifaximin \(550\text{ mg}\) PO/NG misangu ibidi ku dituku (tshintu tshidi katshiyi tshibuela mu tshifu tshidi tshishipa bactérie ya mu tshifu idi ipatula urease).
  9. The HELP Randomized Trial Pearl: Mu HE udi mu lupitadi, kufila \(4\text{ litres}\) ya Polyethylene Glycol 3350 (GoLYTELY) ku diambuluisha dia tshiamu tshia NG mu mêba 4 kudi kujikija disama dia tshiadi dia lukasa mu mêba 24 a kumpala kupita alulose umua.
  10. KUENYI KUELA MU MUTU BUALU BUALU BUA BUALU BUDI BUALU BUA BUALU BUA BUALU BUA KUENZA BUALU BUA KUENZA BUALU BUA KUENZA BUALU BUA KUENZA BUALU BUA KUENZA MU MUTU BUALU BUALU BUDI BUA KUENZA BUALU BUDI BUALU BUA BUALU, ne misangu yonso udi ne bua kulongolola disama dia tshiadi (\(K+ < 3.5\text{ mEq/L}\)) Diakamue.
  11. Muinshi mwa AASLD ne EASL Practice Guidelines, Hepatic Encephalopathy in cirrhosis is a clinical diagnostic: ammoniaque wa mu mishipa udi upetangana bibi ne grade wa West Haven (ne udi ubandishibua mu mushindu wa dishima pikalabu bashiye tourniquet anyi pikala tshintu tshia violet/vert-top katshiyi tshiteka pa ice ne tshinyunguluke mu minite 15). Ino, tshipimu tshia amoniak mu plasma tshidi tshikumbane mu mubedi udi kayi wenda ukola tshidi tshilomba bua kukeba diakamue malu makuabu adi mua kufikisha ku coma (subdural hematoma, non-convulsive status epilepticus, Wernicke encephalopathy, anyi opioid/benzodiazepine overdose).
  12. Bua tshinyi Hypokalemia udi ufila disama dia tshifu: Padi potassium wa mu mashi (\(K+\)) upueka muinshi mua \(3.5\text{ mEq/L}\) (pa tshibidilu kudi loop diuretics), \(\text{H}+\) wa pambelu udi uya mu selile ya tubule ya pabuipi ne tshiadi, ne udi ukebesha **intracellular acidosis and metabolic system: selile ya mu mifuba idi ne acidote idi ikolesha bikole ammoniagenesis wa mu mifuba (iela \(\text{NH}_3\) mupiamupia buludiludi mu mushipa wa mifuba), eku alkalose wa mubidi mujima ukudimuna \(\text{NH}_4+\) udi ne bukole mu **\(\text{NH}_3\) udi kayi ne bukole udi usabuka tshibuelelu tshia buongo. Pingaja potassium ne bukole bua kulama \(K+ \ge 4.0\text{ to }4.5\text{ mEq/L}\).
  13. Dishilangana dia Cirrhotic HE (Type C) ne Fulminant Acute Liver Failure (Type A, where Ammonia \(> 150\text{ to }200\text{ \mu mol/L}\) Causes Fatal Brain Herniation). Mu acute fulminant liver (bu mudi Day 3), ne udi ne disama dia buongo dipite bungi dîba dia zero dia kutuma osmolytes organiques; Disama dia mutshima dia tshitupa tshia ¾ didi dipatula edema cerebral cytotoxique ne uncal/tonsillar herniation. Diakamue, bandisha mutu wa bulalu too ne ku \(30\text{ degrees}\), ela N-Acetylcysteine (NAC) mu mushipa, wela sodium wa mu mashi too ne ku \(145\text{ too ne ku }155\text{ mEq/L}\) wenza mudimu ne \(3\%\) Hypertonic Saline, ** Renuneous Renuncely ** Buondapi (CRRT) bua kumbusha amoniak mu mashi padibu bafunda bua dipanda dia tshiadi tshia lukasa.

Bua tshinyi mashi adi mu tshifu (mashi a mu tshifu) adi 'bombe wa bukole udi ne proteyine ya bungi' bua buongo budi ne disama dia cirrhose

\(100\text{ mL}\) ya mashi onso adibu bapongolola mu tshifu mu tshikondo tshia mashi adi apatuka mu tshifu anyi a mu tshifu adi ne \(15\text{ too ne ku }20\text{ grams}\) ya hemoglobine ne proteine ya plasma. Kabidi, proteyine wa hémoglobine udi mupangile bikole mu amino acid isoleucine (udi ne mushinga mukese menemene mu malu a muoyo). Padi \(1,000\text{ mL}\) ya mashi ibuela mu mala makese ne mu tshifu, bactérie ya glutaminase ne ya urease ya mu mala idi inyangakaja \(180\text{ grams}\) ya proteyine wa mu mashi mu tshipepele tshinene tshia ammonia eku ipuekesha isoleucine, ibueja mubedi wa tshijengu mu 344 Hein 12 too ne ku 24 mêba**. Mubedi yense udi ne disama dia tshiadi udi ne disama dia tshiadi dia tshitupa tshia 2 to ne tshia 4 udi ne tshia kuenza makebulula diakamue bua dipatuka dia mashi mu tshifu (tangila hemoglobine, tshipiminu tshia BUN-to-créatinine, tshikebelu tshia mu tshifu tshia melena, ne tshiamu tshia NG tube aspirate) ne kumupesha prophylactique ** Créatinine (\(1\text{ g/day}\)) + Octreotide + Lactulose/PEG catharsis bua kumbusha mashi mu tshifu.

Mutshi wa mapangadika: disungula dia tshimpitshimpi ne dishintulula dia tshitupa tshia 3 ne tshia 4 tshia disama dia tshiadi

flowchart TD
    A["Mubedi udi ne disama dia cirrhose / Portal Hypertension OR Acute Liver Failure udi uleja nsombelu mushintuluke wa lungenyi: Tshitupa 2 (Lethargy, Disorientation, Asterixis Flapping Tremor) OR grade 3 (Somnolent/Stuporous, Rouses Only to Pain/Voice) OR Grade 4 (Comaresses, Unissive)"] --> B["Tshitupa 1: ABCs ya lukasa, Glucose wa Fingerstick, ne Triage wa njila wa luya: Pesha 500 mg IV Thiamine KUMPALA kua Dextrose; Shi tshitupa tshia 3 (tshikole tshia dipanga dia lungenyi) anyi tshitupa tshia 4 (Coma, GCS <= 8), Enza diakamue ENDOTRACHEAL INTUBATION + Teka Soft Nasogastric (NG) Tube"]
    B --> C["Tshitupa 2: Kumbusha musangu umue bintu bidi bifuanangana ne bintu bidi ne buanga ne kukontonona malu 7 adi afila 'GIB-SICK': 1. STAT Non-Contrast Head CT (Kumbusha Subdural Hematoma); 2. Diagnostic Paracentesis (Rule out SBP: PMN >= 250/mm3); 3. CBC/BUN/Rectal Exam (Kumbusha mashi a mu tshiadi); 4. BMP (Tangila K+ < 3.5, Na+, Alkalosis, AKI); 5. Mashi/Mashi; 6. Ikala ne diuretiques, benzodiazepines ne opioïdes"]
    C --> D{"Manya mushindu wa disama dia tshiadi: Mushindu C (Decompensated Cirrhosis / ACLF) vs. Type A (Fulminant Acute Liver Failure)"}
    D -->|TYPE C: Decompensated Cirrhosis / Portal Hypertension| E{"Mubedi udi mua kupeta manga a Enteral NG / Oral mu bukubi anyi, anyi Ileus / Unintubated Grade 3-4 udiku anyi?"}
    E -->|Grade 3-4 Without NG Access OR Severe Paralytic Ileus / Abdominal Distension| F["RECTAL RETENTION ENEMA PROTOCOL: Instill 300 mL (200 g) Lactulose + 700 mL Water/Saline (1,000 mL Total) via Rectal Balloon Catheter; Kukanga mu minite 30 too ne ku 60 bua kuenza bua tshifu tshia balume tshikale ne acide; Enza kabidi mêba 4 anyi 6 onso"]
    E -->|Intubated with Verified NG Tube OR Awake Grade 2 Patient| G["ENTERAL AMMONIA-PURGING PROTOCOL: 1. Lactulose 30 to 45 mL PO/NG Every 1-2 Hours Until First Tool, Then Titrate (15-45 mL TID-QID) to 2-3 Soft Stools/Day (OR 4 L PEG-3350 over 4h); 2. Ela Rifaximin 550 mg PO/NG BID; 3. Ela IV L-Ornithine L-Aspartate (LOLA 20-40 g/day) shi Refractory"]
    F --> H["Tshitupa 3: Kuondopa ne tshikisu tshikole tshidi tshikebesha: 1. Kulongolola hypokalemia (Lama K+ >= 4.0-4.5 mEq/L bua kuimanyika ammoniagenesis wa mu tshiadi); 2. IV Volume Resuscitation / Albumine for Diuretic AKI; 3. IV Ceftriaxone shi SBP nansha Variceal Bleed; 4. IV Flumazenil (0.2 mg) Trial if Benzodiazepine Trigger Suspected"]
    G --> H
    D -->|TYPE A: Fulminant Acute Liver Failure (INR >= 1.5 + Encephalopathy Without Prior Cirrhosis, Ammonia > 150 umol/L)| I["AKUT LIVER FAILURE CEREBRAL EDEM PROTOCOL (HIGH HERNIATION RISK): 1. Intubation & Elevate Head 30°; 2. Tuadija IV N-Acetylcysteine ​​(NAC); 3. Ela 3% ya Hypertonic Saline (Target Serum Na+ 145-155 mEq/L) + Mannitol Bolus bua ICP Spikes; 4. Tuadija buanga bua dipingaja dia tshiadi (CRRT) bua kumbusha amoniake; 5. Mulongo wa dipanda dia tshifu"]

Pathophysiology: mushindu kayi udi ammonia, glutamine synthetase, ne hypokalemic alkalosis bifikisha ku dikola dia astrocyte ne bua tshinyi Asterixis udi ujimina mu Grade 4 Coma

1. Lungenyi lua "Trojan Horse" lua Astrocyte (Albrecht & Norenberg)

Mu bantu badi ne makanda a mubidi mimpe, ammonia wa mu mishipa ya mu tshiibi udi ufumina ku colonic bacterial urease ne small-intestinal enterocyte glutaminase udi ukudimuka kudi periportal hepatocytes mu urea ku diambuluisha dia Krebs-Henseleit urea cycle. Mu disama dia cirrhose anyi dia tshifu tshikole, amoniak wa mu mishipa udi ubanda misangu 3 too ne ku 10. 1. Kusabuka tshibuikidiji tshia mashi ne buongo: Mu mashi, ammonia udi mu tshipiminu tshidi tshilondeshila ku pH pankatshi pa Ions ya ammonium (\(\text{NH}_4+\), \(98\%\) at pH \(7.40\)) ne Ammonia gas udi kayi ne charge (\(\text{NH}_4+\), \(7.40\)) \(7.40\), \(\text{pK}_a \approx 9.15\))**: $\(\text{NH}_4+ \rightleftharpoons \text{NH}_3\text{ (lipophilic gas)} + \text{H}+\)$ Metabolic anyi respiratory alkalosis (udibu batamba kuenza kudi diuretiques, vomiting, anyi hyperventilation) udi ushintulula equation eu ku dia balume, udi uvudija misangu ibidi anyi isatu tshitupa tshia \(\text{NH}_3\) gaz udi kayi ne bujitu, udi utangalaka bipepele mu tshibuelelu tshia mashi ne buongo mu malu adi anu mu buongo bua muntu (udi anu mu buongo bua muntu) udi ne enzyme glutamine synthetase). 2. Osmotic Swelling + Mitochondrial Poisoning ("The Trojan Horse"): Munda mua cytoplasme wa astrocyte, glutamine synthetase udi usangisha \(\text{NH}_3\) ne glutamate bua kuenza Glutamine: - Osmotic Effect: Disangisha dia bungi dia glutamine munda mua selile didi dienza mudimu bu osmolyte udi ukoka mayi kupitshila ku Njila ya Aquaporin-4 mu njila ya makasa a astrocyte, udi ukebesha Alzheimer Type II astrocytosis (mu disama dia cirrhose dia kashidi, astrocytes idi ifila ndambu wa myool ku diambuluisha dia myool; Dipanga dia tshiadi, kakuena dîba dia kupatula myo-inositol to, bidi bifikisha ku disama dia mu buongo dikole ne dinyanguka dia mutshima udi ushipa dîba dionso didi ammonia wa mu mishipa upita \(150\text{ too ne ku }200\text{ \mu mol/L}\)). - The "Trojan Horse" Mitochondrial Collapse: Glutamine mupiamupia muenza udi uya mu mitochondrie ya astrocyte, mudi phosphate-activated glutaminase umukosolola diakamue mu intra-mitochondrial ammonia (\(\text{NH}_3\)), udi unzulula mushindu wa kupitshi mu mitochondrie, (MP) kupatula mishindu ya oxygène/azote, kujimija ATP, ne kuvudija GABA-A receptor tone (ku diambuluisha dia neurosteroids ya buena ya benzodiazepine bu mudi 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. "Asterixis" (Flapping Tremor) ntshinyi, ne bua tshinyi udi ujimina padi mubedi wenda unyanguka kumbukila ku tshitupa tshia 3 too ne ku tshitupa tshia 4 tshia coma?

  • Mushindu wa kupeta disama dia Asterixis ku luseke lua bulalu: Lomba mubedi bua kuolola bianza bionso bibidi kumpala kuende, kuela bianza biende panyima ("bu kuimanyika mashinyi"), kualabaja minu yende, ne kukanga mêsu ende munkatshi mua tusunsa 30. (Mu mubedi wa mu kalasa ka 3 udi ulala tulu udi kayi mua kubandisha bianza biende, enza mudimu ne tshianza tshia mubedi anyi umulombe bua kufina minu ibidi ya muena mudimu anyi kupatula ludimi luende).
  • Tshidi tshienzeka (Myoclonus mubi): Bishilangane ne disama dia parkinson anyi dikankamika dia mushinga mukole (didi dikokangana dia mifuba), asterixis udi "myoclonus mubi": tshipupu tshia tshimpitshimpi, tshia tshianana $50\text{- to }200\text{-millisecond} mu dikisha dia ku nzembu (anyi flexion) anyi flex Mudimu wa EMG udi mufumina ku dipanga dia mudimu wa diencephalic-reticular motor integration pathways udi ulama tshiona tshia mubidi. Bukole budi bukoka bintu budi bupueka tshianza kumpala mu tshitupa tshîpi, pashishe dipingana dia tshianza mu muaba udibu baleje, bienza bua se: "dikankamika dia mapuapua a nyunyi" didi kadiyi diakane.
  • Critical Clinical Trap: Asterixis udi ulomba tone postural cortical wa budisuile bua kuikalaku. Nunku, asterixis udi umueneka mu West Haven Grades 2 ne Grade 3 ku ntuadijilu, kadi udi ujimina bionso padi mubedi ubuela mu Grade 3 stupor anyi Grade 4 Coma. Kuela meji ne: mubedi udi kayi ne bukole udi wenda ulengejibua anu bualu dikankamika diabu diakajika to; Tangila ni badi bafika ku tshitupa tshia 4 (mudi clonus, hyperreflexie, bimanyinu bia Babinski, anyi decerebrate posturing bipingana pa muaba wa asterixis).

Dilongolola dia luondapu: Mikenji ya West Haven misangisha ne ISHEN Classification ne Glasgow Coma Scale

West Haven Grade (ISHEN Category) Tshitupa tshia lungenyi ne nsombelu wa lungenyi Neuromuscular & Bedbed Physical Findings Tshienzedi tshia disungula dia njila wa luya ne tshia lukasa
Minimal / Covert HE (MHE) Tshikebelu tshia pa tshibidilu ne dilongesha; ki mbimpe anu pa mateta a lungenyi (Diteta dia dibikila dia nyama \(< 15\text{ nyama mu 60 sec}\), Diteta dia dipetangana dia nomba, anyi Stroop App). Kakuena mutoto; bipedi bia pa tshibidilu; njiwu mikole ya njiwu ya mashinyi ne dikuluka. Lactulose (\(15\text{ to }30\text{ mL}\) BID); kukandika diendesha too ne padibu bakuondopa.
Kalasa 1 (Musokome HE) Dishintuluka dia tulu-dijuka dia munya ne butuku (udi ulala dituku dijima, mubike ne kayi ne dikisha butuku bujima), dijimija dia dîba dia kuteya ntema, disanka dikese anyi tshiji, dipanga dia disangisha/dijimija dia malu (Serial 7s). Dikankamika dikese anyi asterixis mutekete/udi kayi umvuangana; dipanga dia difunda dia ku bianza/dipanga dia lungenyi lua dienza (kakuena mua kuzola mutoto wa nsongo itanu to). Tangila malu adi mua kufikisha ku disama (disama dia tshifu, diurètiques); tuadija anyi kubandisha Lactulose wa ku mishiku + Rifaximin.
Kalasa 2 (Overt HE) Dipanga dia lungenyi anyi dipanga dia lungenyi, dipanga dia lungenyi lua dîba (ngondo mubi, tshidimu anyi tshikondo tshibi), ngikadilu mubi, ngakuilu mubi, mupuya muimpe wa mupuya (fetor hepaticus wa dimethyl sulfide). Prominent, unmistakable bilateral Asterixis (flapping tremor), hyperactive deep tendon reflexes, ataxia. Dikonkonona dia tshibambalu tshia malu a mpukapuka: Tangila bionso 7 bidi bijula ​​(LP/paracentesis bua SBP, laboratoire, tshikebelu tshia mashi a mu tshifu) + Lactulose wa ku mishiku udi ne bukole (\(30\text{ mL}\) q1-2h too ne ku tshina).
Mulongo wa 3 (Disama dikole dia patoka, dia lukasa dia luondapu) Somnolence to Semi-Stupor: Ulala tulu, udi mua kujuka anu ku dîyi dikole anyi ku bintu bibi, dipanga dia lungenyi lua Tshikondo ne muaba, ngakuilu udi kauyi umvuangana anyi dibungama dikole. Asterixis udiku pikala mubedi mua kuenza mudimu pamue (anyi mupatuka mu mushindu udi kauyi wenza mudimu); hyperreflexie, ankle clonus, rigidity, ne extensor Babinski signs. Dibuela mu ICU ne Dibueja dia Endotracheal Intubation: KUPESHI bintu bia kunua bia mukana kakuyi dilombola dia njila wa luya; ela NG tube bua Lactulose/PEG + Rifaximin NANSHA ufila Lactulose Retention Enemas (\(300\text{ mL} + 700\text{ mL}\) mayi).
Mulongo wa 4 (Koma wa tshifu, lutatu lua lukasa) Koma mulelela (\(\text{GCS} \le 8\)): kayi wandamuna ku mêyi ne ku malu adi asama. Asterixis udi kayiku (kakuyi dîyi dia budisuile); flaccid quadriparesis anyi decerebrate / decorticate posturing; mêsu adi mavulangana/matekete pikala edema/herniation wa mu buongo (Type A ALF). Dilomba dia lukasa dia kuela mu mashi + Dilengeja dia kapepe: Kufila Lactulose Retention Enemas + NG Lactulose/Rifaximin + IV LOLA + Head CT + Trigger Reversal (anyi 3% Saline + CRRT pikala Fulminant ALF).

Bintu 7 bia kale bidi mua kufikisha ku disama dia tshifu tshia mu tshitupa tshia 3 ne 4 ("GIB-SICK") ne mushindu wa kupingaja tshionso tshia kudibi

Mu bantu bapite pa 80 too ne ku 90 pa lukama badi ne disama dia tshiadi, tshipupu tshikole tshia disama dia tshifu tshia mu tshitupa tshia 3 anyi tshia 4 tshidi tshijudibua kudi tshintu kampanda tshia luondapu tshidi mua kupingana tshianyima. Kuondopa ammoniake ne lactulose kadi kuyi ne tshidi tshikebesha disama edi (bu mudi peritonitis wa bactérie anyi mashi adi apatuka mu mashi) kudi ne lufu lua bungi:

Tshintu tshidi tshikebesha ("GIB-SICK") Misangu Mushindu wa disama Diteta dia tshikebelu tshia tshikebelu ne dishintulula dia malu
1. Dipatuka dia mashi mu tshifu (GIB) (Varices ya mu tshifu/ya mu tshifu, disama dia mu tshifu didi dikola bikole, disama dia mu tshifu) \(15\%\text{ to }25\%\) Mashi adi mu mala adi afila \(15\text{ to }20\text{ g}\) ya isoleucine-deficient protein ku \(100\text{ mL}\) ya mashi \(\rightarrow\) divula dia ammonia mu mala + dipanga dia mashi mu tshiadi. Tangila CBC, BUN/Cr ratio, rectal exam bua melena, ne NG aspirate; tuadija IV Octreotide/Terlipressin + IV Ceftriaxone \(1\text{ g/day}\) + Emergent Endoscopic Band Ligation + Cathartic Lactulose/PEG bua kumbusha mashi mu tshifu.
2. Disama ne Sepsis (Nangananga Spontaneous Bacterial Peritonitis [SBP], UTI, Pneumonia, Cellulitis) \(25\%\text{ to }40\%\) (Tshintu tshidi tshitamba kuenzeka) Cytokines inflammatoires systémiques (TNF-alpha, IL-1beta, IL-6) badi basabuka tshibuelelu tshia mashi ne buongo ne badi benza bua astrocytes ikale ne bukole bua kumona mudi ammoniake ukola nansha padi bungi bua ammoniaque buvula kakese. Enza tshikebelu tshia ku luseke lua bulalu kudi mubedi yonso udi ne disama dia cirrhose ne ascites ne HE mupiamupia (nansha yeye kayi ne luya ne kayi ne kanyinganyinga.), pamue ne mashi/mashi ne CXR; ufila IV Ceftriaxone \(2\text{ g}\) dituku dionso + IV Albumin pikala ascites \(\text{PMN} \ge 250/\text{mm}3\).
3. Benzodiazepines, Opioids, Gabapentinoids, anyi Alcohol \(10\%\text{ to }15\%\) Mifuba ya cirrhose kayena mua kujikija manga adibu bashintulule kudi CYP3A4 to, ne biamu bia GABA-A bia mu buongo bidi bimane kukola bikole. Kukonkonona liste wa manga ne toxicologie wa mashi; lekela manga onso a ditalala, zolpidem, opioids, ne pregabalin; Ela meji bua tshikebelu tshia IV Flumazenil (\(0.2\text{ mg}\) IV mu tusunsa 30, too ne ku \(1\text{ mg}\)) pikalabu bela meji ne: badi badia benzodiazepine.
4. Sodium & Potassium Derangements (Hypokalemia \(K+ < 3.5\), Metabolic Alkalosis, Hyponatremia \(Na+ < 130\)) \(15\%\text{ to }25\%\) Hypokalemia udi usaka ammoniagenesis wa tubule wa pabuipi ne tshiadi; alkalosis udi ukudimuna \(\text{NH}_4+\) ku \(\text{NH}_3\) gaz; hyponatremia udi ukebesha divulangana dia astrocyte osmotic. Tangila STAT BMP; pingaja IV/enteral Potassium Chloride bua kulama \(K+ \ge 4.0\text{ to }4.5\text{ mEq/L}\); longolola hyponatremia bitekete bitekete (\(\le 6\text{ to }8\text{ mEq/L per 24h}\)) bualu cirrhotics badi mu njiwu mikole ya Central Pontine Myelinolysis.
5. Ileus & Constipation \(20\%\text{ to }30\%\) Tshikondo tshile tshia dipita dia bintu bia munda tshidi tshivudija dinyanguka dia urease wa bactérie wa bintu bia azote ne dikuata dia \(\text{NH}_3\) mu tshifu. Enza X-ray wa mu difu/ekzame; kufila Lactulose Retention Enema (\(300\text{ mL}\) mu \(700\text{ mL}\) mayi) + NG Lactulose anyi PEG-3350; lekela manga a anticholinergic/opioïdes.
6. Divula dia creatinine / dijimija dia mayi mu mashi (AKI ne disama dia tshiadi) \(20\%\text{ to }30\%\) Diumusha dia mashi mapite bungi ne furosemide ne spironolactone (anyi paracentesis wa bungi kayi ne albumine) didi difikisha ku dijimija dia mashi mu mishipa, dipangisha dipatuka dia urée/ammonium mu mifuba, ne didi dijula ammoniagenesis wa mu mifuba. KUATA DIAMUE Furosemide ne Spironolactone; kuvudija bunene bua mashi ne \(0.9\%\) Normal Saline anyi \(25\%\) Intravenous Human Albumine (\(1\text{ g/kg/day}\) bua mêba 48).
7. Tshikuku (Didia dia bungi dia proteyine ya nyama) / MIBELU / Disama dia mijilu ya ku tshiibi \(5\%\text{ to }10\%\) TIPS stent (anyi shunt wa dipanda) muteka mupiamupia anyi mualabale bikole udi ufila \(100\%\) ya mashi a ku tshiibi buludiludi mu vena cava wa kuinshi; thrombose wa mu mishipa ya ku tshiibi udi ukebesha ischémie hépatique. Komanda Doppler Ultrasound wa tshifu ne mijilu ya tshifu; Shi dipanga dia TIPS HE dienzeke, radiologie wa diambuluisha udi mua kuenza dipuekesha dia diametre dia stent wa endovascular TIPS. (Note: Kufuishi babedi ba cirrhose ne nzala ya proteyine ya ku dituku ne ku dituku, ikala ne \(1.2\text{ too ne ku }1.5\text{ g/kg/day}\) ku diambuluisha dia proteine ya bimuma/ya mabele ne Branched-Chain Amino Acids [BCAAs] paudi ujuka, bualu dijimija dia mifuba didi dinyanga mifuba bua kubutula mifuba ammonia.).

Mukenji wa luondapu lua lupitadi ne lua ICU

Tshintu tshia luondapu Difila dia manga ne njila mu kalasa ka 3 / 4 HE Mushindu wa kuenza mudimu Malu mabi a mu lupitadi a kuepuka
1. Lactulose (Non-Absorbable Disaccharide) [First-Line Standard] Enteral (via confirmed NG tube): \(30\text{ to }45\text{ mL}\) (\(20\text{ to }30\text{ g}\)) every 1 to 2 hours too ne padi \(\ge 2\) bowel movements occur, then titrate to \(15\text{t{5\text{5\)} to {5\(} mL}\) TID-QID bua 2-3 tuishi tutekete/dituku.
Rectal Retention Enema: \(300\text{ mL}\) Lactulose + \(700\text{ mL}\) Water/Saline (\(1\text{ L}\) total) via rectal balloon catheter retained for 30 to 60 min q4-6h.		 Kuenza kudi bactérie ya mu tshifu mu aside wa lactic/acetic \(\rightarrow\) udi wenza bua tshifu tshikale ne aside (\(\text{pH} < 5.0\)), udi ukuata \(\text{NH}_3\) bu \(\text{NH}_4+\) udi kayi mua kunua, ne udi usukula bintu bia mu tshifu. Njiwu ya dienza dia mabele a bungi: Kufila \(60\text{ mL}\) kunyima kua mêba 2 kakuyi mpata munkatshi mua matuku kudi kufikisha ku disama dia tshifu tshikole (\(> 6\text{ stools/day}\)), difikisha ku hypernatremie mikole (\(Na+ > 150\text{EqL/day}\)), KI, hypodomic dinyanguka dia koma. Misangu yonso, ikala utekesha panshi padi tuishi tutuadija.
2. Polyethylene Glycol 3350 (PEG-3350, GoLYTELY) [Rapid Catharsis Alternative] \(4\text{ Litres}\) mufila ku diambuluisha dia Nasogastric Tube mu meba 4 (anyi \(2\text{ L}\) + Lactulose). Udi umbusha ne lukasa luonso bukoya bua azote, mashi, ne bactérie idi ipatula amoniak mu tshitupa tshijima tshia GI kayi wimanyina pa dienza dia bactérie to. Bijadikibua mu HELP Randomized Controlled Trial (JAMA Intern Med) bua kujikija HE wa tshimpitshimpi mu mêba 24 ne lukasa lua bungi kupita lactulose nkayende.
3. Rifaximin (Xifaxan) [Mandatory Add-On Therapy] \(550\text{ mg}\) PO anyi mutshibule ku diambuluisha dia NG tube misangu ibidi ku dituku (anyi \(400\text{ mg}\) TID) muela ku Lactulose. Tshintu tshidi katshiyi tshikuata (\(< 0.4\%\) tshidi tshikuata) tshidi tshisungula rifamycine tshidi tshipangisha bikunyibua bidi bipatula urease mu tshifu ne tshikepesha disama dia mu tshifu. Kuela Rifaximin ku Lactulose kudi kukepesha lufu lua bantu badi ne disama dia HE dikole ne kudi kukepesha bungi bua bantu badi mua kubuela mu lupitadi bua HE mu matuku atshilualua ne 58 pa lukama (Bass et al., NEJM).
4. Intravenous L-Ornithine L-Aspartate (LOLA) [Second-Line Metabolic Scavenger] \(20\text{ to }40\text{ grams/day}\) IV infused continuously over 4 to 8 hours diluted in \(500\text{ mL}\) IV fluid (available in UK, EU, Asia, Canada, and Latin America). Udi ufila bintu bidi bienza mudimu bimpe (ornithine ne aspartate) bidi bikolesha dienza dia urea-cycle ne glutamine synthetase mu mifuba ya mifuba bua kumbusha ammoniaque mu mashi. Biyampe bininge mu mateta a mpukapuka a Grade ¾ HE padibu bamusakidila ku lactulose; Tangila serum creatinine mu disama dikole dia tshiadi. (Mu États-Unis, oral/NG Sodium Phenylbutyrate anyi Glycerol Phenylbutyrate ne IV Branched-Chain Amino Acids [BCAAs] badi ne mudimu wa muomumue wa diumusha ammonia).
5. Intravenous Flumazenil [Targeted Diagnostic/Therapeutic Rescue] \(0.2\text{ mg}\) IV mu tusunsa 30, mupingaja mu tshitupa tshia minite umua too ne ku \(1.0\text{ too ne ku }2.0\text{ mg}\) maximum. Mu mushindu wa mvita, udi ukandika muaba udi benzodiazepine ulamakaja pa GABA-A receptors (udi upingaja benzodiazepines ya pambelu ne neurosteroïdes ya cirrhose ya munda). Udi ufila dibika dia tshitupa tshîpi dia dîba 1 too ne ku 2 mu 20% too ne ku 30% ya babedi ba mu tshitupa tshia ¾ tshia HE (kuanyishila tshikebelu tshia mitu ne kuepuka dibueja dia tshiamu tshia nzembu padibi bifumina ku lorazepam/diazepam); kabiena bikumbana mu dikuatshika dia benzodiazépine dia kashidi anyi mu malu a kale a tshimpumpu.

Nomba ya njiwu ya mu tshijengu ne mikenji ya luondapu

  • États-Unis ne Canada: Ela 911 bua mubedi yonso udi ne disama dia cirrhose anyi disama dia tshifu dikole didi dipeta dipanga dia lungenyi, dipanga dia lungenyi, disama dia asterix, anyi dipatuka dia mashi mu tshifu. Dilombola didi dilonda Association Americane pour la Study des Maladies du Liver (AASLD) Practice Guideline on Hepatic Encephalopathy in Chronic Liver Disease ne AASLD Position Paper on Acute Liver Failure.
  • Royaume-Uni: Tela 999 anyi uya ku tshibambalu tshia malu a njiwu tshia NHS. Baminganga badi balonda British Society of Gastroenterology (BSG) / BASL Decompensated Cirrhosis Care Bundle ne NICE Guidelines (NG50 / TA337), idi ilomba bua kuenza tshiamu tshia ascitic tap mu mêba 6, kuenza trigger screening, lactulose/rifaximine therapy, ne IVthiamine (pathinnex).
  • Buobumue bua matunga a ku Mputu: Ela 112. Baminganga badi balonda European Association for the Study of the Liver (EASL) Clinical Practice Guidelines on the Management of Hepatic Encephalopathy (2022 Update), approval West Haven/ISHEN grading, lactulose retention enemas in Grade ¾, rifaximine, ne L-Orthine L-O (LOLA).
  • Australie ne Nouvelle-Zélande: Ela 000 mu Australie anyi 111 mu Nouvelle-Zélande ne ulonde mikenji ya Gastroenterological Society of Australia (GESA) cirrhosis ne acute liver failure.

Nkonko itubu bela misangu ya bungi

Bua tshinyi kuena ne tshia kupangisha proteyine mu biakudia bia mubedi udi ukola ku disama dia tshiadi?

Munkatshi mua makumi a bidimu, mikanda ya kale ya malu a luondapu ivua yambila babedi bavua ne disama dia cirrhose mu tshilema bua kudia "biakudia bidi ne proteyine mikese" bua kuepuka dienza dia amoniak. Mikenji ya lelu ya malu a tshifu (AASLD ne EASL) mmimbushe tshishiki dipangisha dia proteyine. Buatshinyi? Mu mubedi udi ne disama dia cirrhose udi tshifu tshiende katshiyi mua kumbusha kabidi amoniake, mifuba ya mifuba idi ilua tshitupa tshia kumpala tshia mubidi tshidi tshikuatshisha bua kumbusha amoniake mu mashi (mijilu idi yenza mudimu ne glutamine synthetase bua kukuata amoniake mu mashi). Kupangisha proteyine mu biakudia kudi kufikisha ku dijimija dia mifuba mikole (sarcopenie), didi dinyangakaja mifuba ya mubedi idi ifila ammonia ne dienza bua disama diabu dia Hepatic Encephalopathie dikale dibi menemene. Padi mubedi ujuka mu tshikondo tshia koma tshikole, udi ne tshia kudia 1.2 too ne ku 1.5 grame ya proteyine ku kilograme wa bujitu bua mubidi dituku dionso, ne kuela meji ku proteyine ya muitu, ya mabele, ne ya amino acid (BCAA) idi mitangalake mu biakudia bikese bia misangu ne misangu ne biakudia bia butuku bidi ne proteyine ya bungi.

Mmunyi mudi Lactulose Enema wenza mudimu padi mubedi udi mu koma kayi mua kumina, ne bua tshinyi mâyi a mu pompi kaena akumbana to?

Mu tshitupa tshia 3 anyi tshia 4 tshia disama dia tshifu, mubedi udi ne tshiji tshikole anyi udi mu koma bua kumina bimpe, ne ileus wa paralytique udi mua kutekesha mâyi adibu bafila ku diambuluisha dia tshiamu tshia mu tshifu. Kuela enema muenza ne 300 mL ya syrup wa Lactulose musambakaja ne 700 mL ya mayi (1 litre mu kabujima) buludiludi mu tshifu ne kukanga tshintu tshia kuela mu tshifu munkatshi mua minite 30 too ne ku 60 kudi kufila lactulose buludiludi kudi bactérie ya mu tshifu mudi 70 pa lukama ya amoniake mienza. Bishilangane na tshiamu tshia enema tshia mayi a mu pompi (tshidi anu tshisukula bintu bia mu tshifu), bactérie ya mu tshifu idi ivuija lactulose ne lukasa luonso mu aside lactique, ipuekesha pH wa munda mua tshifu muinshi mua 5,0. Aside au udi ukudimuna kapepe ka amoniak (NH3) mu ion ya amoniak (NH4+), ne udi bushuwa ukoka amoniak mu mishipa ya mashi ya mu tshifu bua kumubueja mu tshina tshia aside bua kumupatula padibu bumbusha enema.

Bua tshinyi kufila Lactulose wa bungi kudi mua kunyangakaja disama dia koma dia mubedi?

Tshipatshila tshia luondapu lua lactulose kunyima kua dilengeja dia kumpala ntshia kuenza anu 2 anyi 3 ya mala adi ne acide ku dituku, ki mbua 10 ya mayi a mu tshifu ku dituku to. Bu mudi lactulose muikale tshintu tshidi tshikoka mayi mimpe mu mashi bua kuya mu mala, kufila bungi bua bungi bua lactulose dîba dionso kudi kufikisha ku dijimija dia mayi a bungi mu tshifu. Mu meba 24 to ne ku 48, mubedi udi upeta disama dikole dia hypernatremie (sodium mu mashi udi ubanda pa mutu pa 150 too ne ku 160 mEq/L) ne disama dia tshiadi tshia hypovolemic. Disama dia hypernatremie dikole ne dipanga dia mâyi mu mubidi bidi bifikisha ku disama dia metabolic encephalopathie ne bidi bipangisha mifuba bua kupatula urée ne amoniaque, bifikisha mubedi ku dibuela mu koma eku baminganga batungunuka ne kulomba lactulose mu tshilema.

Bua tshinyi dipanga dia potassium mu mashi (Hypokalemia) didi difikisha ku disama dia tshiadi tshikole kudi babedi badi banua manga a mayi (Furosemide)?

Babedi badi na cirrhose ne tshifu tshidi ne mayi (ascites) batu misangu ya bungi banua manga a diurèse bu mudi furosemide (Lasix), adi enza bua mifuba ijimije potassium mu mashi. Padi potassium mu mashi upueka muinshi mua 3.5 mEq/L, potassium udi umbuka munda mua tubule tua mu mifuba ne ions ya hydrogène (acide) idi ibuela munda bua kuangata muaba wende. Padibu bumvua ne: munda muabu mmulue ne aside, selile ya tubule ya pabuipi ne mifuba idi ituadija dienza dia amoniake dikole (ammoniagenesis wa mu mifuba) bua kukuba aside wa mu mashi, ipompa bungi bunene bua amoniake mupiamupia buludiludi mu mijilu ya mu mifuba. Mu tshikondo tshimue tshimue, mashi adi pambelu pa selile adi alua a alcaline (alkalose métabolique), adi akudimuna ammonium (NH4+) udi ne bukole bua bungi mu gaz wa amoniak udi kayi ne bujitu (NH3) udi ubuela buludiludi mu buongo. Kupingaja patupu potassium mu mashi pa mutu pa 4.0 too ne ku 4.5 mEq/L kudi kukanga tshiapu tshia amoniak tshia mu tshiadi.

Miaba ne buludiki bua mbulamatadi

  • European Association for the Study of the Liver (EASL): EASL Clinical Practice Guidelines on the Management of Hepatic Encephalopathy (2022 Update, Journal of Hepatology): West Haven/ISHEN Grading, Trigger Identification, Lactulose Enemas, Rifaximin, and LOLA.
  • Tshisumbu tshia bena Amerika tshia dilonga dia masama a tshiadi (AASLD) ne EASL Joint Practice Guideline (Vilstrup H, Amodio P, Bajaj J et al., Hepatology): Hepatic Encephalopathie in Chronic Liver Disease: Practice Guideline by AASLD and EASL.
  • New England Journal of Medicine (NEJM, Bass NM et al. & Wijdicks EFM): Rifaximin Treatment in Hepatic Encephalopathy; Dikonkonona dia mudimu wa luondapu wa disama dia tshiadi.
  • JAMA Internal Medicine (HELP Randomized Trial, Rahimi RS, Singal AG et al.): Lactulose vs. Polyethylene Glycol 3350-Electrolyte Solution for Treatment of Overt Hepatic Encephalopathy.
  • Tshisumbu tshia bena Grande-Bretagne tshia malu a tshifu (BSG) ne tshisumbu tshia bena Grande-Bretagne tshia dilonga dia tshifu (BASL): Tshisumbu tshia dilama dia disama dia tshiadi: Dilama dia lukasa dia mêba 24 a kumpala.

Enza kalasa ka diambuluisha dia kumpala ne yukila ne bena mudimu

Mukanda ewu udi ufila dimanya dia lukasa ne dilongesha dia disungula dia malu a tshimpitshimpi ne kawena upingana pa muaba wa malu a hepatologie, a gastroenterologie, a neurocritical anyi a luondapu lua lukasa to. Bua kulonga mishindu ya kuteka muntu udi kayi mumanye lungenyi mu muaba wa kuondopibua, kulombola malu a tshimpitshimpi a mu njila wa luya, ne kuenza malu a nshindamenu a diambuluisha dia muoyo, wangate tulasa tua diambuluisha dia kumpala tudibu banyishe ku diambuluisha dia Croix-Rouge, St John Ambulance, anyi kudi mufidi wa diambuluisha wa muaba unudi.

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