Hepatic coma - this is a serious condition depression of the central nervous system and its functions associated with disorders in the circulatory system, occurring due to severe liver failure, due to a significant relief of portal blood system.
Hepatic coma usually occurs under the action of the body severe intoxication as a result of mechanical damage to the integrity of the liver or the death of most of the cells of the organ as a result of various diseases, acute and chronic.The share of patients got to the hospital with signs of hepatic coma, accounting for about one third of patients under the age of 40 years.All, without exception, have a history of liver failure.
reasons hepatic coma
rate of occurrence of a pathological condition is directly proportional to the degree of damage to the central nervous system.Not the last role is played here by toxins such as ammonia, aromokisloty, phenolic derivatives.These substances toxic effect on the brain, which leads to lower
Hyperaminoacidemia hyperammonemia and portal anastomosis due to the development in patients with a history of cirrhosis, resulting in the ability of the liver cells do not synthesize urea.Therefore, great importance for the development of a pathological state is the accumulation in the organism decomposition products, which results in metabolic acidosis, a further transition in alkalosis.
According to doctors classify the causes of hepatic coma in the endogenous and exogenous.
Endogenous hepatic coma occurs in people recover from acute viral hepatitis, or so-called Botkin's disease, which causes necrosis of the liver tissue.Endogenous causes may also be the use of high doses of alcohol, drug abuse or eating poisonous mushrooms.They also include mechanical causes such as liver vein thrombosis in the acute stage, schistosomiasis or error during operative ligation of the hepatic artery.Less common are pregnant steatosis, liver cancer, blood transfusion for incompatible blood group and other accessories.
Exogenous hepatic coma patients suffering from cirrhosis of the liver aggravated process of circulatory disorders in the portal vein.Mixed hepatic coma etiology relevant a combination of both factors.
symptoms of hepatic coma
Clinic is growing most slowly, but a small percentage of patients suffering from cirrhosis of the liver as a result of suffering a hepatitis, an acute beginning.
signs of hepatic coma progress within 1-2 weeks.First, patients complain of loss of appetite, a lack of taste and fatigue.Appears severe headache, patients do not sleep, abdominal pain, and note the intolerable itching.Sometimes in mucosal bleeding is observed.Then, the patient clinical picture deteriorates.There is agitation, complicated by epileptiform seizures, often accompanied by twitching of individual muscle groups of the body.
By severity expressive motor behavior as amended EEG waves distinguish the following stages of hepatic coma:
♦ During precoma characterized by anxiety, alternating with sadness and a sense of causeless apathy.Thinking slows down, there are problems with falling asleep.Answers to the questions are adequate, others will know, but there is no focus, the patient find it difficult to solve even the simplest tasks on logic.Any significant deviations in the electroencephalogram not.
♦ The next stage - is threatening hepatic coma.There alternating bouts of excitation, drowsiness and fits of deep depression.Develop violation hepatocellular nature: a characteristic sweet, putrid smell of the mouth, yellow skin and others.Pronounced clinical signs of hemorrhagic syndrome: the accumulation of blood in the organs of the gastrointestinal tract and in the mucous membranes of the oral cavity.The amplitude of the waves on the EEG increased the rhythm slows down to 7-8 cycles per second.
♦ At the stage of coma actually complete absence of consciousness, dilated pupils, no reaction to light.Observed clonic seizures in rare cases fibrillar spasmodic contraction of the muscles.Determined regidnost skeletal muscles.The patient's face resembles a mask - smoothed nasolabial folds and frontal, eye slit is wider at the mouth angle omitted.The oppression of the respiratory center appears abnormal occurrence or Kussmaul breathing Biota, which is a sign of acidosis.Characterized by cardiovascular changes: quickens the pulse, blood pressure plummets, bad heart sounds are heard, there are noises.Body temperature increased, often possible sepsis.It is possible the development of oliguria and blood leukocytosis.EEG gipersinhronnye produces delta waves, alternating with contour line.
Treatment of hepatic coma
to assign adequate treatment is necessary before starting to make a differential diagnosis of cerebral circulation disorders and neuropsychiatric disorders in patients suffering from alcoholism.
«Liver» smell, an increase in the blood indices of bilirubin, hemorrhagic diathesis, and similar symptoms to a greater extent characteristic clinical picture of hepatic coma in these cases is not observed.
If diagnosed correctly, the patient begin treatment based on the stage of coma, from which he was hospitalized.Under precoma restrict the content of the daily diet of protein and 50 grams, and with an increase in symptoms completely eliminated.Assign cleansing enemas and laxatives to reduce intoxication.For the suppression of intestinal microflora take into semisynthetic penicillin group antibiotics, as an option - ampicillin at a dose of 6 g per day.Emergency medical actions carried out in the hospital or intensive care unit.
Treatment of hepatic coma aimed primarily at improving the functional parameters of the body by balancing the water and electrolyte balance.Intravenously administered 5% glucose solution and 800 ml with addition in 30 ml Asparkama.It requires a larger dose of the hormone such as prednisolone to 1000 mg per day for prevention of necrotic death of liver cells.
to normalize body functions assigned 1% solution of nicotinic acid and 10 ml intramuscularly Ribaflavina 1% solution of 3 ml intravenous solution of 5% of vitamin B1 and vitamin B6, 5 ml each intramuscularly.
struggle with high acidity of blood is carried out by introducing a 4% sodium chloride solution for intravenous drip injection in a volume of 500 ml, alkalosis neutralized by the introduction of drugs potassium.
of the modern methods of treatment and plasmapheresis hemosorbtion popular drugs through a catheter into the umbilical vein.With great excitement actual Haloperidol 1 g enema, with clonic spasms intravenous Relanium of 2.0 ml.Diuretics are prohibited categorically.
For the prevention of oxygen starvation of the brain and liver prescribed inhalations with humidified oxygen, metered oxygen foam in the stomach and is performed in a pressure chamber oxygenation lasting about 2 hours.
With a favorable prognosis after the patient comes out of the coma, it is advisable to drink plenty of liquids and to appoint a special diet, rich in carbohydrates, with a minimal amount of fat and protein.According to the testimony continued symptomatic treatment: anticonvulsants, sedatives, cardiovascular and other means.If
marked symptoms of DIC must be heparin, which is controlled by the amount of coagulation.Droperidol and Eufillin prescribed to improve blood supply to the liver.Proteolytic processes in the organ reduced Gordoks, Kontoikal which are inhibitors of proteolytic enzymes.
If therapy remains impotent, develops liver failure, which leads to the need for extracorporeal dialysis.Liver transplantation in this case, is questioned, since its effectiveness has not yet been proved.
forecast hepatic coma
important to understand that the forecast is important for those studying ways to treat very severe hepatic coma, characterized by a high mortality rate (around 80%).This can be explained by the fact that there is no treatment for the causes of the disease and the result depends on the regenerative ability of the liver.Taking this into account we can say that factors such as age, length of time from the onset of jaundice and to the first signs of a coma, EEG parameters, the intensity progression of neuropsychiatric signs and more, are entitled to the formulation of the initial forecast.
with timely begun treatment of hepatic coma prognosis is favorable, however, if the history of chronic renal failure - the poor, as the coma and is able to regress in a few months is prone to relapse.Equally important is the depth of the lesions in the early stages so there is a chance for a full recovery, and clinical signs of the coma itself, the process is unfortunately irreversible.