ENCEPHALOPATHY

Atan Baas Sinuhaji

Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan

ENCEPHALOPATHY
DISORDER OF CEREBRAL
FUNCTION ==> Inflammation (-)

DIGESTIVE TRACT
1. Hepatic Encephalopathy
2. Kernicterus
3. Reye Syndrome
4. Dehydration +disorder of consciousness
5. Hypo/hypernatremia
severe hypophosphatemia

GE + SEVERE DEHYDRATION
CIRCULATORY DISTURBANCES

OXYGENATION

CONSCIOUSNESS

GE+SEVERE DEHYDRATION+ENCEPHALOPATHY
COMA SHOCK

P
< 1 mg %
Energy

Dysfunction of
leucocytes &
thrombocytes

RBC
O2 delivery
Cerebral Anoxia

Rhabdomyolisis

KERNICTERUS
= BILIRUBIN ENCEPHALOPATHY

Unconsciousness
Spasme
Convulsion
Mortality 75%
Recovery - Blind
- Deafness
- Neuromusc. Incoord.
(chorea athetosis)

Th

1. EXCHANGE TRANSFUSION ==> UNCONJUG.

BILIRUBIN > 20 mg %
2. PHOTOTHERAPY
3. PHENOBARBITAL
4. INHIBITION OF ABSORPTION
5. TIN PROTOPORFIRIN
INHIBITION OF BILIVERDIN TO BILIRUBIN
6. SUPPORTIVE

HEPATIC ENCEPHALOPATHY
= LIVER FAILURE
= HEPATOCELLULER FAILURE
= HEPATOCYTIC FAILURE
= GAGAL HATI
HEPATIC COMA
PORTO SYSTEMIC ENCEPH

FULMINANT 2 WEEKS
SUBFULMINANT 2-8 WEEKS

CLINICAL GRADING OF HEPATIC ENCEPHALOPATHY

I.

CONFUSED

II.

DROWSY

III.

STUPOROUS

IV.

- COMA
- DEEP COMA

HEPATIC COMA

Systemic

t
a
p
He

.
V
ic

Inferior v. cava

liver

portal v.
t
gu

Porto systemic encephelopathy

LIVER FAILURE

ENCEPHALOPATHY
COAGULOPATHY
HALLMARK

DYSFUNCTION
INTRAHEPATIC
METABOLISM

THERAPY :
1. VENTILATION
2. WATER & ELECTROLYTES
3. COAGULOPATHY:
- Vitamin K
- Transfusion : Fresh Frozen Plasma
4. BLOOD AMMONIA (NH3) :
- lactulose
- neomycine Nephrotoxic
5. REDUCING INTRACRANIAL PRESSURE :
- cerebral edem : steroid, mannitol, etc.
- hypokarbia Cerebral Blood Flow
6. MONITORED CLOSELY FOR INFECTION
7. HEPATOTOXIC DRUGS WITHDRAWN :
- eg : Sedative

ENCEPHALOPATHY

REYE SYNDROME

FATTY DEGENERATION
BLOOD NH3

Mitochondrial dysfunction
HYPOGLYCEMIA
ACUTE

SALICYLIC ACID

Th

1. CONTROL OF INTRACRANIAL PRESSURE

2. WATER & ELECTROLYTES
3. ADEQUATE OXYGENATION
4. CONTROL OF HYPOGLICEMIA

5. COAGULOPATHY IS MANAGED
6. EXCHANGE TRANSFUSION

GASTROINTESTINAL
HEMORRHAGE
Atan Baas Sinuhaji
Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan

GI BLEEDING
GUT
OUT

- BLOOD DISORDERS :
LEUKEMIA

IN

BLOOD PER OS

- SYSTEMIC
- RUPTURE OF THE
AORTA

HEMATEMESIS

BLOOD PER
ANUM

HEMATEMESIS
DIGESTIVE
TRACT

INGESTION

INFANTS
-NIPPLES
-HEMORRHAGIC DISEASE

CHILDREN
EPISTAXIS

OF THE NEWBORN
-INGESTION OFMATERNAL BLOOD
(MATERNAL SWALLOWED BLOOD
SYNDR.)

APT DOWNEY TEST

- MUCOSAL LESION
- VARICEAL BLEEDING

NEW BORN

Hb F

50-90 %

ALKALI RESISTENT

Hb A

Hb A2

HEMATEMESIS
MUCOSAL LESION PORTAL HYPERTENSION

PEPTIC
ULCER

ESOPHAGEAL
VARICES
GASTRITIS

DRUGS
- SALICYLIC ACID

PEPTIC ULCER
PROLONGED
EXCESS ACID

BREAKDOWN IN
BARRIER

INFECTION

H. PYLORI

ACETYLCHOLINE

PROSTAGLANDIN

ZOLLINGER ELLISON
SYNDR. NON B ISLET
CELL

HISTAMIN
GASTRIN

MUSCARINIC
RECEPTOR

H2 RECEPTOR
(-)
ADENYLCYCLASE
c AMP

PROTEINKINASE

Na K ATP ase

HCL

GASTRIN
RECEPTOR

TREATMENT
1. MUCOSAL PROTECTION

SUCRALFATE
2. ACID SECRETION
3. NEUTRALIZED ACID

ANTACIDE

4. ERADICATION OF H. PYLORI
- AMOXICILLIN 50 mg/Kg/day
- CLARITHROMYCIN 15 mg/Kg/day
- OMEPRAZOLE 1 mg/Kg/day

2 WEEKS

ACID SECRETION
1. H2 RECEPTOR BLOCKER : CIMETIDINE
RANITIDINE
2. PROTON PUMP INHIBITOR :
OMEPRASOLE
3. PROSTAGLANDIN SYNTHETASE:
MISOPROSTOL
4. ANTICHOLINERGIC : PIRENZEPINE

INFECTION OF H. PYLORI
1. INVASIVE

=TISSUE

MICROSCOPIC
CULTURE
UREA TEST

=BLOOD : IgG

2. NONINVASIVE
-UREA BREATH TEST
-STOOL-BASED TEST
=H.pylori Ag
=H.pylori DNA

BLEEDING PER ANUM

OCCULT

HEMOCCULT TEST

OVERT

MELENA

HEMATOCHEZIA

Materials

Heme protein

Hydrogen peroxidase

Colorless guaiac

Blue quinone
25

HEMATOCHEZIA

WITH
DIARRHOEA

WITHOUT
DIARRHOEA

DYSENTERY

- ANAL FISSURE

SYNDROME

- RECTAL POLYP

WITHOUT
STOOLS

INVAGINATION

DYSENTERY SINDROME = BLOODY DIARRHOEA

1. DYSENTERY
- BACILLARY
- AMOEBIC
2. Enterocolitis
- Cows milk allergy
3. Trichuriasis
4. Others

- Entero invasive E coli

- C. jejuni