Stages Stage 1: slight altered mood or behavior including sleeping rhythm, light flapping tremor i Stage 2: drowsy inappropriate behavior Stage 3: Coma but arousable, speech incomprehensible Stage 4: Coma, no response to painful stimuli, no flapping tremor
Stages – Stage 1： slight altered mood or behavior including sleeping rhythm, light flapping tremor ； – Stage 2：drowsy, inappropriate behavior – Stage 3： Coma but arousable, speech incomprehensible – Stage 4：Coma , no response to painful stimuli, no flapping tremor
Clinical presentation Coma Drowsiness Confusion Sleeping disorder Apathy Childishness
Clinical presentation Sleeping disorder Apathy Childishness Confusion Drowsiness Coma
Pathogenesis Multifarious toxins>Dysfunction of CNs (No obvious morphological change) Several hypotheses to uncover the mystery
Pathogenesis Multifarious toxins → Dysfunction of CNS (No obvious morphological change) Several hypotheses to uncover the mystery
1. Ammonia intoxication hypothesis Supporting evidence 80% of he show increased plasma ammonia level patients with hepatocirrhosis have elevated level of ammonia o symptom of he and alteration in electroencephalogram(eeg after high protein diet
Supporting evidence ◆ 80% of HE show increased plasma ammonia level ◆ patients with hepatocirrhosis have elevated level of ammonia ◆ symptom of HE and alteration in electroencephalogram(EEG) after high protein diet 1. Ammonia intoxication hypothesis
Plasma ammonia: <59umol/L NH3 production NH clearance urea cycle Under normal condition, the production and the clearance of nh3 is in balance
NH3 production NH3 clearance （ urea cycle ） Under normal condition, the production and the clearance of NH3 isin balance Plasma ammonia: <59μmol/L