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1. Grading of Hepatic Encephalopathy (HE)

West Haven Criteria (WHC) - the most widely used system

• Grades 0 and Minimal = Covert HE (CHE) - no clinical evidence of mental change but abnormal special tests
• Grades 2-4 = Overt HE (OHE) - clinically obvious

SONIC Classification (Spectrum of Neurocognitive Impairment in Cirrhosis)

1. Unimpaired - no clinical, neurophysiologic, or neuropsychometric abnormalities
2. Covert HE - clinically normal but abnormal cognitive/neurophysiologic tests (= MHE + Grade 1)
3. Overt HE - Grade 2 and above; the key distinguishing feature is disorientation to time

Types by Underlying Disease:

• Type A - associated with acute liver failure (ALF)
• Type B - associated with portosystemic bypass without intrinsic liver disease
• Type C - associated with cirrhosis and portal hypertension (most common)

Key Clinical Features:

• Asterixis (flapping tremor, elicited by wrist hyperextension) - hallmark of overt HE; present in grades 2-3, absent in coma
• EEG changes: triphasic wave patterns appear at grade 2-3, disappear in coma
• Pathophysiology: hyperammonemia → impaired blood-brain barrier, glutamine-mediated astrocyte swelling, cerebral edema

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2. Signs of Splenomegaly

Symptoms

• Pain and heaviness in the left upper quadrant (LUQ)
• Massive splenomegaly causes early satiety (compresses stomach)
• LUQ pain from capsule stretch, infarction, or capsule inflammation
• Visible fullness in the LUQ that descends on inspiration (massive splenomegaly)

Physical Signs

Bimanual Palpation Technique:

• Patient supine with flexed knees; examiner's left hand on lower rib cage pulling skin toward costal margin; right hand starts in left lower quadrant and moves toward left costal margin, feeling the spleen tip as the patient inspires deeply
• Bimanual palpation in right lateral decubitus adds nothing to the supine examination

Differentiating enlarged spleen from other masses:

• Has a medial notch
• Moves with respiration
• Dull to percussion (no resonant colon between spleen and anterior abdominal wall)
• Cannot get above it

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3. Areas of Portocaval (Portosystemic) Anastomosis

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4. Methods of Percussion of the Spleen

1. Nixon's Method

• Patient positioned on right lateral decubitus (right side down) so spleen lies above the colon and stomach
• Percussion starts at the lower level of pulmonary resonance in the posterior axillary line, proceeding diagonally toward the lower midanterior costal margin
• Normal: upper border of dullness is 6-8 cm above the costal margin
• Splenomegaly: dullness >8 cm in an adult

2. Castell's Method

• Patient supine
• Percuss the lowest intercostal space in the anterior axillary line (8th or 9th space)
• Normal: resonant note during both expiration and full inspiration
• Splenomegaly: dull note on full inspiration (spleen comes down to occupy this space)

3. Traube's Semilunar Space Percussion

• Patient supine with left arm slightly abducted
• Borders of Traube's space: 6th rib superiorly, left midaxillary line laterally, left costal margin inferiorly
• Percuss from medial to lateral margins during normal breathing
• Normal: resonant sound throughout
• Splenomegaly: dull percussion note in Traube's space

Accuracy Notes (Harrison's):

• Sensitivity: 56-71% for palpation, 59-82% for percussion
• Reproducibility is better for palpation than percussion
• Both are less reliable in obese patients or patients who just ate (full stomach gives dullness)
• Recommended approach: percuss first; if positive, proceed to palpation - if spleen is palpable, splenomegaly is likely
• Ultrasonography is the current gold standard (normal spleen = max cephalocaudad diameter of 13 cm)