[Pathogenesis and therapy of hepatic coma]

Even today, there is a markedly high rate of lethality resulting from an acute or chronic failure of the liver function. The reason of this seems to be the still unknown pathogenesis of the hepatic coma. In general, therapeutical measures will involve medical treatment of single symptoms on the basis of empirically made experience. However, any success will primarily depend on an early recognition of the approaching lethal breakdown and on the corresponding therapeutical measures taken before the final stage has been reached. Studies on its pathogenesis have to focus mainly on changes affecting the structure of the amino acid in the serum, in particular as regards the differences of the molecular ratio between aromatic and ramified-chain amino acids. The increased amount of serum ammonia does not seem to have major influence on the genesis of hepatic encephalopathy as has previously been assumed for a long time. Any treatment has to set in early, preferably in the General Department, as approximately 60% of cerebral malfunctions can already be registered in a zero coma state. Measures will involve detoxification, parental nutrition as well as substitution of such liver-generated substances as are not sufficiently produced at that stage. Any worked-out therapeutical scheme ought to be handled in a most flexible way in order to allow for an immediate response to the sometimes fast-changing clinical symptoms.