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==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>
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>


{| class="wikitable" align="right"
{| 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.
|+ 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.
! NH<sub>3</sub> level!!Grade 0<br/>(no encephalopathy)!! Grade 1!! Grade 2!! Grade 3!! Grade 4
! NH<sub>3</sub> level!!Grade 0<br />(no encephalopathy)!! Grade 1!! Grade 2!! Grade 3!! Grade 4
|-
|-
| > 50|| 10 (33%)|| 18 (67%)|| 14 (52%)|| 25 (89%)|| 12 (92%)
| > 50|| 10 (33%)|| 18 (67%)|| 14 (52%)|| 25 (89%)|| 12 (92%)
Line 36: Line 36:
| < 25 || 8 (27%)|| 0 (0%)|| 4 (15%)|| 0 (0)%)|| 1* (8%)
| < 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%)
| 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.
| 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>.
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"
{| class="wikitable"
Line 47: Line 47:
!  &nbsp;!![[sensitivity (tests)|sensitivity]]!! [[specificity (tests)|specificity]]
!  &nbsp;!![[sensitivity (tests)|sensitivity]]!! [[specificity (tests)|specificity]]
|-
|-
| > 50 μmol/L|| align="center"| 76%|| align="center"|67%
| > 50 μmol/L|| align="center" | 76%|| align="center" |67%
|-
|-
| > 25 μmol/L|| align="center"| 93%|| align="center"| 27%
| > 25 μmol/L|| align="center" | 93%|| align="center" | 27%
|}
|}


Line 60: Line 60:
*[[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>
*[[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>
*[[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>
*[[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 end-stage [[Liver diseases|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>
*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==

Revision as of 16:59, 19 January 2018

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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]

Venous ammonia and level of encephalopathy.[2]
Number (%) of patients.
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[2][3][4] although its ability is less clear in chronic liver disease[5].

Accuracy of the venous ammonia[2]
  sensitivity specificity
> 50 μmol/L 76% 67%
> 25 μmol/L 93% 27%

Ammonia levels over 123 are likely to improve with lactulose therapy.[6]

An ammonia level more than 200 strongly suggests hepatic encephalopathy.[2]

Other important laboratory findings in hepatic encephalopathy may include:

References

  1. 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.
  2. 2.0 2.1 2.2 2.3 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)
  3. 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)
  4. 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)
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.

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