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Gastroenterology (Expert Forum)
Treating hepatic encephalopathy and getting a second opinion
Answered by
Kevin Pho, MD - Internal Medicine
KevinMD.com
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
Treating hepatic encephalopathy and getting a second opinion
by jjarman, Mar 26, 2004 12:00AM
A friend pointed me to your site and I've found it to be a wealth of information.
My father is 77 and was diagnosed with Cirrhosis about two years ago. He's been a model patient and followed all the dietary an drug requirements to the letter. For the past 8 to 9 months, it could be longer, he has been on a yo-yo of extreme water retention, high volumes of diuretics, extreme muscle cramps, reduced diuretics, and back to extreme water retention. He has been very active his entire life and is exercising as often as possible even now, but the disease and treatments have greatly weakened him.
About six weeks ago we had to take him to the hospital because he had become extremely disoriented. He was diagnosed as having had a mild stroke. This past Friday he was having the same problems and we took him to the hospital and they've diagnosed hepatic encephalopathy. I tend to think that was what he had all along. His ammonia level was 30 when we brought him in, they got it down to 20 and he was better so they lowered his meds and transferred him to the rehad ward. When I called him in his new room in the evening, he was much worse than he had ever been and the nurses didn't seem to care. When I spoke to his doctor, he told me he seemed fine when he saw him in the morning but would have a hospital doctor check on him. I received a call back from the doctor telling me he reviewed my father's latest blood work and the ammonia level shot up to 169. He was very bad last night and I fear that he may not have long to live. Now that you have the background, here are some of my questions.
Is it normal to not be able to hone in on a stablizing suite of drugs to control hepatic encephalopathy?
Would my father's advanced age rule him out for a liver transplant?
I really would like to get a second opinion. Can you recommend a specialist in the Baltimore MD area?
How can I get the hospital and doctors to take his case more seriously? I would think someone would have identified his deteriorating condition without my having to call his doctor in a panic.
Any help you can provide is greatly appreciated.
Thanks
My father is 77 and was diagnosed with Cirrhosis about two years ago. He's been a model patient and followed all the dietary an drug requirements to the letter. For the past 8 to 9 months, it could be longer, he has been on a yo-yo of extreme water retention, high volumes of diuretics, extreme muscle cramps, reduced diuretics, and back to extreme water retention. He has been very active his entire life and is exercising as often as possible even now, but the disease and treatments have greatly weakened him.
About six weeks ago we had to take him to the hospital because he had become extremely disoriented. He was diagnosed as having had a mild stroke. This past Friday he was having the same problems and we took him to the hospital and they've diagnosed hepatic encephalopathy. I tend to think that was what he had all along. His ammonia level was 30 when we brought him in, they got it down to 20 and he was better so they lowered his meds and transferred him to the rehad ward. When I called him in his new room in the evening, he was much worse than he had ever been and the nurses didn't seem to care. When I spoke to his doctor, he told me he seemed fine when he saw him in the morning but would have a hospital doctor check on him. I received a call back from the doctor telling me he reviewed my father's latest blood work and the ammonia level shot up to 169. He was very bad last night and I fear that he may not have long to live. Now that you have the background, here are some of my questions.
Is it normal to not be able to hone in on a stablizing suite of drugs to control hepatic encephalopathy?
Would my father's advanced age rule him out for a liver transplant?
I really would like to get a second opinion. Can you recommend a specialist in the Baltimore MD area?
How can I get the hospital and doctors to take his case more seriously? I would think someone would have identified his deteriorating condition without my having to call his doctor in a panic.
Any help you can provide is greatly appreciated.
Thanks
Doctor's Answer
by Kevin Pho, MD, Mar 29, 2004 12:00AM
, Mar 29, 2004 12:00AM
To answer your questions:
1) Lactulose is typically used for chronic prevention of hepatic encephalopathy. Limitation of protein intake (to 70 g/day) is also recommended. The titration of individual protein tolerance after an episode of acute hepatic encephalopathy should permit the design of an individual diet for each patient. Despite these measures, encephalopathy can still occur - there is no guaranteed prevention.
2) Age by itself should not rule him out for a liver transplant.
3) Another opinion can be found here:
http://www.abim.org/dp/apps/physdir5.htm
4) If you feel your providers are not listening to you, it is always your right to obtain another opinion or provider that you feel comfortable with.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Bibliography:
Ferenci. Treatment of hepatic encephalopathy. UptoDate, 2004
1) Lactulose is typically used for chronic prevention of hepatic encephalopathy. Limitation of protein intake (to 70 g/day) is also recommended. The titration of individual protein tolerance after an episode of acute hepatic encephalopathy should permit the design of an individual diet for each patient. Despite these measures, encephalopathy can still occur - there is no guaranteed prevention.
2) Age by itself should not rule him out for a liver transplant.
3) Another opinion can be found here:
http://www.abim.org/dp/apps/physdir5.htm
4) If you feel your providers are not listening to you, it is always your right to obtain another opinion or provider that you feel comfortable with.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Bibliography:
Ferenci. Treatment of hepatic encephalopathy. UptoDate, 2004
