Gastroenterology Education and CPD for trainees and specialists

1. Which one of the following statements regarding Hepatic Encephalopathy (HE) is false?

1. West Haven criteria defines the different stages of HE
2. Asterixis is generally absent in stage3 and stage4
3. Asterixis is most commonly seen in stage2 but may be seen in stage1
4. The intact liver clears almost all of the portal vein ammonia, converting it into glutamine and preventing entry into the systemic circulation.
5. GI bleed is not a risk factor for developing HE- FALSE

Explanation :West Haven criteria: Stage 0. Lack of detectable changes in personality or behaviour. Asterixis absent. Stage 1. Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria or depression. Asterixis can be detected. Stage 2. Lethargy or apathy. Disorientation. Inappropriate behaviour. Slurred speech. Obvious asterixis. Stage 3. Gross disorientation. Bizarre behaviour. Semistupor to stupor. Asterixis generally absent. Stage 4. Coma.

2. Which one of the following statements regarding Hepatic Encephalopathy (HE) is TRUE?

1. The intact liver clears almost all of the portal vein ammonia, converting it into glutamine
2. Portal ammonia is derived from both the urease activity of colonic bacteria and the deamidation of glutamine in the small bowel.
3. Ammonia as a key factor in the pathogenesis of HE.
4. a.Rifaxamin can be added to lactulose if no improvement after 48 hours
5. a.All of above

3. Which one of the following statements regarding Hepatic Encephalopathy (HE) is false?

1. Lactulose is broken down by intestinal disaccharidases - FALSE
2. Lactuose lowers the pH and thus converts NH3 to nonabsorbable NH4
3. Lactulose through NG tube is given on presentation 45ml and then hoursly until evacuation occurs
4. Laxative also removes ammoniagenic substrate
5. One year survival is only 40% once HE sets in cirrhotic patients.

Explanation :Lactulose is a first-line pharmacological treatment of HE. Lactulose (galactosido-fructose) is not broken down by intestinal disaccharidases and thus reaches the colon, where bacteria will metabolize the lactulose to acetic acid and lactic acid. This lowers the colonic pH and thus favours the formation of the nonabsorbable NH4+ from NH3, trapping NH3 in the colon and effectively reducing plasma ammonia concentrations. Other effects like catharsis also contribute to the clinical effectiveness of lactulose. Bowel cleansing with enemas is a rapid and effective method to remove ammoniagenic substrates. So antibiotics can be added to lactulose after 48 hours, if the response has been poor. The goal of antibiotic therapy in the treatment of HE is to reduce the mass of enteric bacteria that produce ammonia Rifaximin (400 mg t.i.d) is the drug of choice, but is expensive.

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MCQ On Hepatic Encephalopathy

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