Hepatic encephalopathy laboratory findings: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Hepatic encephalopathy}} | {{Hepatic encephalopathy}} | ||
{{CMG}} {{AE}} | {{CMG}};{{AE}}{{MMJ}} | ||
==Overview== | |||
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name]. | |||
OR | |||
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3]. | |||
OR | |||
[Test] is usually normal among patients with [disease name]. | |||
OR | |||
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication]. | |||
OR | |||
There are no diagnostic laboratory findings associated with [disease name]. | |||
==Laboratory Findings== | ==Laboratory Findings== | ||
The normal [[plasma]] level of [[ammonia]] is 12 - 48 μmol/L.<ref name="pmid9761809">{{cite journal |author=Kratz A, Lewandrowski KB |title=Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Normal reference laboratory values |journal=N Engl J Med |volume=339 |issue=15 |pages=1063 |year=1998 |pmid9761809=|doi=10.1056/NEJM199810083391508 |url=http://content.nejm.org/cgi/content/full/339/15/1063/ |issn=}}</ref> | |||
A study in 2019 found that elevated plasma ammonia (≥79.5 µmol/L) predicted HE grade 3 or more<ref name="pmid30703853">{{cite journal| author=Sheikh MF, Mookerjee RP, Agarwal B, Acharya SK, Jalan R| title=Prognostic Role of Ammonia in Cirrhotic Patients. | journal=Hepatology | year= 2019 | volume= | issue= | pages= | pmid=30703853 | doi=10.1002/hep.30534 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30703853 }} </ref>. | |||
* | |||
* | {| class="wikitable" align="right" | ||
|+ Venous ammonia and level of encephalopathy.<ref name="pmid12637132">{{cite journal |author=Ong JP, Aggarwal A, Krieger D, ''et al'' |title=Correlation between ammonia levels and the severity of hepatic encephalopathy |journal=The American journal of medicine |volume=114 |issue=3 |pages=188–93 |year=2003 |month=February |pmid=12637132|doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302014778 |issn=}}</ref><br />Number (%) of patients. | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |NH<sub>3</sub> level | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Grade 0<br />(no encephalopathy) | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Grade 1 | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Grade 2 | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Grade 3 | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Grade 4 | |||
|- | |||
| > 50|| 10 (33%)|| 18 (67%)|| 14 (52%)|| 25 (89%)|| 12 (92%) | |||
|- | |||
| 25-20 || 12 (40%)|| 9 (33%)|| 5 (19%)|| 3 (11%)|| 0 | |||
|- | |||
| < 25 || 8 (27%)|| 0 (0%)|| 4 (15%)|| 0 (0)%)|| 1* (8%) | |||
|- | |||
| Total<br />patients || 30 (100%)|| 27 (100%)|| 2 (100%)3||28 (100%)||13 (100%) | |||
|- | |||
| colspan="6" |*This patient's ammonia level was approximately 20 μmol/L. | |||
|} | |||
The [[ammonia]] level can help diagnose encephalopathy<ref name="pmid12637132">{{cite journal |author=Ong JP, Aggarwal A, Krieger D, ''et al'' |title=Correlation between ammonia levels and the severity of hepatic encephalopathy |journal=The American journal of medicine |volume=114 |issue=3 |pages=188–93 |year=2003 |month=February|pmid=12637132 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302014778 |issn=}}</ref><ref name="pmid13978712">{{cite journal |author=Stahl J |title=Studies of the blood ammonia in liver disease. Its diagnostic, prognostic, and therapeutic significance |journal=Annals of internal medicine |volume=58 |issue= |pages=1–24|year=1963 |month=January |pmid=13978712 |doi= |url= |issn=}}</ref><ref name="pmid12663235">{{cite journal |author=Nicolao F, Efrati C, Masini A, Merli M, Attili AF, Riggio O |title=Role of determination of partial pressure of ammonia in cirrhotic patients with and without hepatic encephalopathy |journal=Journal of hepatology |volume=38|issue=4 |pages=441–6 |year=2003 |month=April |pmid=12663235 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0168827802004361 |issn=}}</ref> although its ability is less clear in [[chronic liver disease]]<ref name="pmid25117134">{{cite journal| author=Ge PS, Runyon BA| title=Serum ammonia level for the evaluation of hepatic encephalopathy. | journal=JAMA | year= 2014 | volume= 312 | issue= 6 | pages= 643-4 | pmid=25117134 | doi=10.1001/jama.2014.2398 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25117134 }} </ref>. | |||
{| class="wikitable" | |||
|+ Accuracy of the venous ammonia<ref name="pmid12637132">{{cite journal |author=Ong JP, Aggarwal A, Krieger D, ''et al'' |title=Correlation between ammonia levels and the severity of hepatic encephalopathy |journal=The American journal of medicine |volume=114 |issue=3 |pages=188–93 |year=2003 |month=February |pmid=12637132 |doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302014778 |issn=}}</ref> | |||
!align="center" style="background:#4479BA; color: #FFFFFF;" + |Venous ammonia levels | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Sensitivity | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Specificity | |||
|- | |||
| > 50 μmol/L|| align="center" | 76%|| align="center" |67% | |||
|- | |||
| > 25 μmol/L|| align="center" | 93%|| align="center" | 27% | |||
|} | |||
[[Ammonia]] levels over 123 are likely to improve with [[lactulose]] therapy.<ref name="pmid19555401">{{cite journal| author=Sharma P, Sharma BC, Sarin SK| title=Predictors of nonresponse to lactulose for minimal hepatic encephalopathy in patients with cirrhosis. | journal=Liver Int | year= 2009 | volume= 29 | issue= 9 | pages= 1365-71 | pmid=19555401 | doi=10.1111/j.1478-3231.2009.02067.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19555401 }} </ref> | |||
An [[ammonia]] level more than 200 strongly suggests hepatic encephalopathy.<ref name="pmid12637132">{{cite journal| author=Ong JP, Aggarwal A, Krieger D, Easley KA, Karafa MT, Van Lente F et al.| title=Correlation between ammonia levels and the severity of hepatic encephalopathy. | journal=Am J Med | year= 2003 | volume= 114 | issue= 3 | pages= 188-93 | pmid=12637132 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12637132 }} </ref> | |||
=== | Other important laboratory findings in hepatic encephalopathy may include: | ||
*[[Hyponatremia]]<ref name="pmid19455127">{{cite journal| author=Yun BC, Kim WR| title=Hyponatremia in hepatic encephalopathy: an accomplice or innocent bystander? | journal=Am J Gastroenterol | year= 2009 | volume= 104 | issue= 6 | pages= 1390-1 | pmid=19455127 | doi=10.1038/ajg.2009.287 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19455127 }} </ref> | |||
*[[Hypokalemia]]<ref name="pmid25436277">{{cite journal| author=Gaduputi V, Chandrala C, Abbas N, Tariq H, Chilimuri S, Balar B| title=Prognostic significance of hypokalemia in hepatic encephalopathy. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 133 | pages= 1170-4 | pmid=25436277 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436277 }} </ref> | |||
*[[Anemia]] is a predictor of hepatic encephalopathy in some patients with [[Cirrhosis|hepatic cirrhosis]].<ref name="pmid23452072">{{cite journal| author=Kalaitzakis E, Josefsson A, Castedal M, Henfridsson P, Bengtsson M, Andersson B et al.| title=Hepatic encephalopathy is related to anemia and fat-free mass depletion in liver transplant candidates with cirrhosis. | journal=Scand J Gastroenterol | year= 2013 | volume= 48 | issue= 5 | pages= 577-84 | pmid=23452072 | doi=10.3109/00365521.2013.777468 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23452072 }} </ref> | |||
*[[Liver function tests]]: patients may have abnormal [[bilirubin]], [[albumin]], [[Aspartate transaminase|AST]], [[Alanine transaminase|ALT]], [[Aspartate transaminase|AST]]/[[Alanine transaminase|ALT]], [[INR]] due to underlying hepatic disease.<ref name="pmid28680841">{{cite journal| author=Djiambou-Nganjeu H| title=Hepatic Encephalopathy in Liver Cirrhosis. | journal=J Transl Int Med | year= 2017 | volume= 5 | issue= 1 | pages= 64-67 | pmid=28680841 | doi=10.1515/jtim-2017-0013 | pmc=5490964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28680841 }} </ref> | |||
*Hyper[[creatine]]<nowiki/>mia may be present in patients with [[Liver diseases|end-stage liver disease.]]<ref name="pmid22791939">{{cite journal| author=Hartleb M, Gutkowski K| title=Kidneys in chronic liver diseases. | journal=World J Gastroenterol | year= 2012 | volume= 18 | issue= 24 | pages= 3035-49 | pmid=22791939 | doi=10.3748/wjg.v18.i24.3035 | pmc=3386317 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22791939 }} </ref> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Hepatology]] | [[Category:Hepatology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 04:04, 26 February 2019
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Hepatic encephalopathy laboratory findings On the Web |
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Risk calculators and risk factors for Hepatic encephalopathy laboratory findings |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]
Overview
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR
There are no diagnostic laboratory findings associated with [disease name].
Laboratory Findings
The normal plasma level of ammonia is 12 - 48 μmol/L.[1] A study in 2019 found that elevated plasma ammonia (≥79.5 µmol/L) predicted HE grade 3 or more[2].
| NH3 level | Grade 0 (no encephalopathy) |
Grade 1 | Grade 2 | Grade 3 | Grade 4 |
|---|---|---|---|---|---|
| > 50 | 10 (33%) | 18 (67%) | 14 (52%) | 25 (89%) | 12 (92%) |
| 25-20 | 12 (40%) | 9 (33%) | 5 (19%) | 3 (11%) | 0 |
| < 25 | 8 (27%) | 0 (0%) | 4 (15%) | 0 (0)%) | 1* (8%) |
| Total patients |
30 (100%) | 27 (100%) | 2 (100%)3 | 28 (100%) | 13 (100%) |
| *This patient's ammonia level was approximately 20 μmol/L. | |||||
The ammonia level can help diagnose encephalopathy[3][4][5] although its ability is less clear in chronic liver disease[6].
| Venous ammonia levels | Sensitivity | Specificity |
|---|---|---|
| > 50 μmol/L | 76% | 67% |
| > 25 μmol/L | 93% | 27% |
Ammonia levels over 123 are likely to improve with lactulose therapy.[7]
An ammonia level more than 200 strongly suggests hepatic encephalopathy.[3]
Other important laboratory findings in hepatic encephalopathy may include:
- Anemia is a predictor of hepatic encephalopathy in some patients with hepatic cirrhosis.[10]
- Liver function tests: patients may have abnormal bilirubin, albumin, AST, ALT, AST/ALT, INR due to underlying hepatic disease.[11]
- Hypercreatinemia may be present in patients with end-stage liver disease.[12]
References
- ↑ Kratz A, Lewandrowski KB (1998). "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Normal reference laboratory values". N Engl J Med. 339 (15): 1063. doi:10.1056/NEJM199810083391508.
- ↑ Sheikh MF, Mookerjee RP, Agarwal B, Acharya SK, Jalan R (2019). "Prognostic Role of Ammonia in Cirrhotic Patients". Hepatology. doi:10.1002/hep.30534. PMID 30703853.
- ↑ 3.0 3.1 3.2 3.3 Ong JP, Aggarwal A, Krieger D; et al. (2003). "Correlation between ammonia levels and the severity of hepatic encephalopathy". The American journal of medicine. 114 (3): 188–93. PMID 12637132. Unknown parameter
|month=ignored (help) - ↑ Stahl J (1963). "Studies of the blood ammonia in liver disease. Its diagnostic, prognostic, and therapeutic significance". Annals of internal medicine. 58: 1–24. PMID 13978712. Unknown parameter
|month=ignored (help) - ↑ Nicolao F, Efrati C, Masini A, Merli M, Attili AF, Riggio O (2003). "Role of determination of partial pressure of ammonia in cirrhotic patients with and without hepatic encephalopathy". Journal of hepatology. 38 (4): 441–6. PMID 12663235. Unknown parameter
|month=ignored (help) - ↑ Ge PS, Runyon BA (2014). "Serum ammonia level for the evaluation of hepatic encephalopathy". JAMA. 312 (6): 643–4. doi:10.1001/jama.2014.2398. PMID 25117134.
- ↑ Sharma P, Sharma BC, Sarin SK (2009). "Predictors of nonresponse to lactulose for minimal hepatic encephalopathy in patients with cirrhosis". Liver Int. 29 (9): 1365–71. doi:10.1111/j.1478-3231.2009.02067.x. PMID 19555401.
- ↑ Yun BC, Kim WR (2009). "Hyponatremia in hepatic encephalopathy: an accomplice or innocent bystander?". Am J Gastroenterol. 104 (6): 1390–1. doi:10.1038/ajg.2009.287. PMID 19455127.
- ↑ Gaduputi V, Chandrala C, Abbas N, Tariq H, Chilimuri S, Balar B (2014). "Prognostic significance of hypokalemia in hepatic encephalopathy". Hepatogastroenterology. 61 (133): 1170–4. PMID 25436277.
- ↑ Kalaitzakis E, Josefsson A, Castedal M, Henfridsson P, Bengtsson M, Andersson B; et al. (2013). "Hepatic encephalopathy is related to anemia and fat-free mass depletion in liver transplant candidates with cirrhosis". Scand J Gastroenterol. 48 (5): 577–84. doi:10.3109/00365521.2013.777468. PMID 23452072.
- ↑ Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.
- ↑ Hartleb M, Gutkowski K (2012). "Kidneys in chronic liver diseases". World J Gastroenterol. 18 (24): 3035–49. doi:10.3748/wjg.v18.i24.3035. PMC 3386317. PMID 22791939.