Delirium in the context of Liver diseases

Etiology

• !Liver Failure → Hyperammonemia

• Many hypothesis

• Consequence of portosystemic shunting in portal hypertension

  

Precipitants

• Physiological stresser
  • Infection
  • Electrolyte imbalance
  • GIB - GI Bleeding
• Medication causing Sedation (Drowsy)
• Common Sedating medication

Presentation

• Early:
  • Day-night reversal, Insomnia/Sleep disturbances
  • Personality change
  • Cognitive change
  • Asterixis (Stage 2)
• Late:
  • Confusion
  • Disorientation
  • Nystagmus
  • Lethargic (GCS 13–15)
  • Coma (GCS ≤ 8) (Stage 4)

Management

Acute Management

• *Do NOT measure serum ammonia
  • ONLY for coma without known liver cause

1. Treat underlying cause
2. Lactulose → Acidifies colonic environment to reduce ammonia absorption
3. Monitor risk of aspiration in eating/drinking