Hepatic Coma

Abstract

Hepatic coma is a treatable condition often in contrast with the underlying hepatic disease. The treatment, to a large extent, rests on known physiologic or biochemical abnormalities. Understanding these altered mechanisms aids in providing rational treatment. The treatment of hepatic coma involves at least the following:o1.Recording and graphing, when appropriate, a large number of observations and measurements so that the physician may learn at a glance the state of consciousness, the functioning of homeostatic mechanisms and the condition of the liver.2.Elimination or treatment, where possible, of all factors which might have precipitated the state. These include: (a) control of gastrointestinal bleeding, (b) attention to fluid and electrolyte balance, (c) avoidance of surgical procedures, (d) prevention and prompt treatment of infection and (e) discontinuance of certain diuretics (ammonium salts, chlorothiazide, acetazolamide).3.Oral administration of an antibiotic; broad-spectrum drugs such as neomycin, kanamycin and paramomycin are preferred, unless uremia is present, at which time chlortetracycline may be given.4.If the patient is in coma, the insertion of a stomach tube for feeding and the administration of an antibiotic.5.Moderate protein feeding during the prodrome or precoma, but elimination of protein if the condition progresses or coma ensues. When protein is climinated, calorie feeding must be continued with partially hydrolyzed starch by tube and glucose parenterally.6.“Cleansing the gastrointestinal tract” if blood or much protein is present or if the patient has been constipated.7.Provision for the intake of vitamins, including folic acid and choline, if food restriction is undertaken.8.Consideration of glutamic acid and arginine therapy.9.Consideration of colectomy or ileosigmoidostomy for patients difficult to control for long periods.10.Continuous attention to the treatment of the basic liver disease and its other complications: gastrointestinal bleeding, ascites and renal failure. Recording and graphing, when appropriate, a large number of observations and measurements so that the physician may learn at a glance the state of consciousness, the functioning of homeostatic mechanisms and the condition of the liver. Elimination or treatment, where possible, of all factors which might have precipitated the state. These include: (a) control of gastrointestinal bleeding, (b) attention to fluid and electrolyte balance, (c) avoidance of surgical procedures, (d) prevention and prompt treatment of infection and (e) discontinuance of certain diuretics (ammonium salts, chlorothiazide, acetazolamide). Oral administration of an antibiotic; broad-spectrum drugs such as neomycin, kanamycin and paramomycin are preferred, unless uremia is present, at which time chlortetracycline may be given. If the patient is in coma, the insertion of a stomach tube for feeding and the administration of an antibiotic. Moderate protein feeding during the prodrome or precoma, but elimination of protein if the condition progresses or coma ensues. When protein is climinated, calorie feeding must be continued with partially hydrolyzed starch by tube and glucose parenterally. “Cleansing the gastrointestinal tract” if blood or much protein is present or if the patient has been constipated. Provision for the intake of vitamins, including folic acid and choline, if food restriction is undertaken. Consideration of glutamic acid and arginine therapy. Consideration of colectomy or ileosigmoidostomy for patients difficult to control for long periods. Continuous attention to the treatment of the basic liver disease and its other complications: gastrointestinal bleeding, ascites and renal failure.