Fetor hepaticus
Fetor hepaticus—a distinctive musty, sweet breath odor—characterizes hepatic encephalopathy, a life-threatening complication of severe liver disease. The odor results from the damaged liver’s inability to metabolize and detoxify mercaptans produced by bacterial degradation of methionine, a sulfurous amino acid. These substances circulate in the blood, are expelled by the lungs, and flavor the breath.
Emergency interventions
If you detect fetor hepaticus, quickly determine the patient’s level of consciousness. If he’s comatose, evaluate his respiratory status. Prepare to intubate him and provide ventilatory support if necessary. Start a peripheral I.V. line for fluid administration, begin cardiac monitoring, and insert an indwelling urinary catheter to monitor output. Obtain arterial and venous samples for analysis of blood gases, ammonia, and electrolytes.
History and physical examination
If the patient is conscious, closely observe him for signs of impending coma. Evaluate deep tendon reflexes, and test for asterixis and Babinski’s reflex. Be alert for signs of GI bleeding and shock, common complications of end-stage liver failure. Also, watch for increased anxiety, restlessness, tachycardia, tachypnea, hypotension, oliguria, hematemesis, melena, or cool, moist, pale skin. Place the patient in a supine position with the head of the bed at 30 degrees. Administer oxygen if necessary, and determine the patient’s need for I.V. fluids for albumin replacement. Draw blood samples for liver function tests, serum electrolyte levels, hepatitis panel, blood alcohol count, a complete blood count, typing and crossmatching, a clotting profile, and ammonia level. Intubation, ventilation, or cardiopulmonary resuscitation may be necessary. Evaluate the degree of jaundice and abdominal distention, and palpate the liver to assess the degree of enlargement.
Obtain a complete medical history, relying on the patient’s family if necessary. Focus on any factors that may have precipitated liver disease or coma, such as a recent severe infection; overuse of sedatives, analgesics, (especially acetaminophen), alcohol, or diuretics; excessive protein intake; or recent blood transfusion, surgery, or GI bleeding.
Medical causes
Hepatic encephalopathy
Fetor hepaticus usually occurs in the final, comatose stage of this disorder but it may occur earlier. Tremors progress to asterixis in the impending stage, which is also marked by lethargy, aberrant behavior, and apraxia. Hyperventilation and stupor mark the stuporous stage, during which the patient acts agitated when aroused. Seizures and coma herald the final stage, along with decreased pulse and respiratory rates, positive Babinski’s reflex, hyperactive reflexes, decerebrate posture, and opisthotonos.
Special considerations
Effective treatment of hepatic encephalopathy reduces blood ammonia levels by eliminating ammonia from the GI tract. You may have to administer neomycin or lactulose to suppress bacterial production of ammonia, give sorbitol solution to induce osmotic diarrhea, give potassium supplements to correct alkalosis, provide continuous gastric aspiration of blood, or maintain the patient on a low-protein diet. If these methods prove unsuccessful, hemodialysis or exchange transfusions may be performed.
During treatment, closely monitor the patient’s level of consciousness, intake and output, and fluid and electrolyte balance.
Pediatric pointers
A child who is slipping into a hepatic coma may cry, be disobedient, or become preoccupied with an activity.
Geriatric pointers
Along with fetor hepaticus, elderly patients with hepatic encephalopathy may exhibit disturbances of awareness and mentation, such as forgetfulness and confusion.
Patient counseling
Advise the patient to restrict his intake of dietary protein to as little as 40 g/day. Recommend that he eat vegetable protein rather than animal protein sources. Inform the patient that medications used to treat and prevent hepatic encephalopathy do so by causing diarrhea, so he shouldn’t stop taking the drug when diarrhea occurs.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Body odor
» Next page:
Breath with ammonia odor [Uremic fetor] (Professional Guide to Signs & Symptoms (Fifth Edition))
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