Hepatic encephalopathy vs. alcohol withdrawal Alcohol withdrawal Hepatic encephalopathy Pathophysiology includes… - Neuroexcitation due to inadequate stimulation of GABA receptors - Excessive activity of inhibitory GABA receptors by various toxins Typical clinical presentation to ICU - Agitated delirium - Seizure(s) - Hypoactive delirium - Somnolence, coma Epidemiology - Occurring within days of EtOH cessation - History of prior episodes of withdrawal upon cessation of alcohol. - Often patients too sick to drink significant EtOH, may have stopped drinking in remote past (obtain a good history!) - History of prior episodes of hepatic encephalopathy Physical examination - Generalized ongoing tremor - Sympathetic activation (e.g. hypertension, tachycardia) - Visual hallucinations - Asterixis (“flapping tremor”) Response to low - dose benzodiazepine - May have minimal effect (patients generally relatively resistant to benzodiazepines). - May cause somnolence. The Internet Book of Critical Care, by @PulmCrit