James Williams, MS, DO, FACEP

Jim, I want to close by discussing how patients are discharged, which is usually outside your purview. I don’t anticipate you discharge many of these patients, but I want to talk about the admission fully. If a patient who is admitted with HE [hepatic encephalopathy] is nearing discharge, some things that are important to keep in mind are how we can strategize for them to get appropriate, follow-up, treatment, and hopefully not end up back in the emergency department [ED] within a month or so. At my institution [Weill Cornell Medical College], we try and educate the patient about the disease. It’s not necessarily straightforward for them to understand why their brain is affected by cirrhosis and how that has a lot to do with bacteria in their intestines. The medications lactulose and rifaximin help prevent that, but we try to discuss the basics of the pathophysiology of hepatic encephalopathy, how ammonia plays a role in having adequate bowel movements, and how taking this antibiotic can help prevent them from ending up back in the hospital.

We prescribe them the medications they need. Rifaximin often requires prior authorization, so we want to make those prescriptions clear in terms, saying that the indication is overt hepatic encephalopathy and they were hospitalized with it. If they’re intolerant of lactulose or if they failed lactulose, it’s important to include the right ICD-10 [International Classification of Diseases, Tenth Revision] code. We try to start that process early so that they don’t run into a lapse in medications. That brings up a question for you. Do you see patients whose major reason for coming in is that they didn’t have access to medication?

 That’s a challenge for a lot of patients, particularly those living on their own. Perhaps they don’t have a strong support network. Maybe they did have a strong support network, but recurrent HE sometimes exhausts family members and leaves patients on their own. It’s a challenge if they can’t get support, don’t know how to get it, or won’t get it. The No. 1 thing we can do is provide good follow-up for these patients.

I imagine you have a great case manager network at your facility. We have it at our facility too, although I don’t discharge most of these patients. On the backside, when hospitalists discharge them, we have case managers calling these patients to make sure they’re getting their medication and to see how they’re doing. Those 2 open-ended questions—are you getting your medications? How are things going?—are helpful to minimize progression for relapse.

In the emergency department, the most important thing we can do to help with this continuity of understanding of HE and ongoing treatment is to diagnose HE. Rather than admitting the patient with a diagnosis of a generic altered mental status, which doesn’t help much, try to refine it: yes, they did have a GI [gastrointestinal] bleed plus or minus SBP [spontaneous bacterial peritonitis], but also mention hepatic encephalopathy explicitly because that will help them then get the medication as an inpatient but also as an outpatient.

Such important points. I completely agree with the case-management aspect. We can prevent a significant subset of admissions by someone just calling them and picking up on early encephalopathy that can be managed at home. For example, sometimes patients need to take a little extra lactulose. That could avoid an emergency department visit or an admission that can be costly in a number of ways: outcome, days in the hospital, dollars spent. Sometimes they need a sooner follow-up appointment than what’s been scheduled for them. If someone is checking in the first few days and they recognize that, that can potentially be a way of keeping them out of the hospital. Thank you for bringing that up and the importance of attaching that diagnosis to their hospitalization, even though they might have several diagnoses. These patients are medically complex, but in terms of access to medications, having that HE diagnosis—both in the hospitalization and potentially on the prescription—is important.

We learned this decades ago with congestive heart failure as it proliferated: when we have close follow-up with case management, we can minimize any recurrence of ED visits or hospitalizations and access to medications. That’s key. No. 1 you have to make the diagnosis, and No. 2, you have to take your medication to treat it.

Exactly. If we can do that reliably or achieve that on behalf of our patients, we’ll be taking much better care of them and preventing a lot of admissions, or at least the preventable ones.

 Thank you for this rich and informative discussion. Before we conclude, I’d like to get final thoughts from you. Dr Williams, is there anything you want to add?

It’s been a pleasure having this conversation with you and our colleagues. Thank you for the opportunity. My final thought is that in the emergency department, when you have complex patients with altered mental status, you have to at least consider hepatic encephalopathy, as not just the sole diagnosis but often a joint diagnosis. You have to treat both aggressively and start early just as you would any other patient in the emergency department. Remember, it’s not a unifying diagnosis of a singular diagnosis of sepsis. We typically have to treat sepsis and HE aggressively. Even if it’s subtle, if it’s not over. With HE, which is easy to diagnose, you want to start treatment early and don’t want to depend on your serum ammonia level. It’s a clinical diagnosis.

 I like that as a closing thought: don’t depend on your serum ammonia level. Thank you. To our viewing audience, we hope you found this 

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Drs Arun Jesudian and James William discuss approaches for proper discharge planning and transition of care and how this can reduce readmission for patients with hepatic encephalopathy.

Discharge Planning and Transition of Care in HE

I want to ask you to grade emergency medicine. What are some things that are missed sometimes? What would you tell all the emergency physicians to consider in these patients?

First and foremost, the approach that you suggested is an ideal 1 for emergency medicine physicians. I completely understand that there’s so much going on in your typical emergency department, with many types of patients coming through the door. By no means do I want someone to think exactly the way I do in terms of liver disease. Keeping hepatic encephalopathy [HE] on the differential diagnosis for any patient is important because this might be their first episode, and they might have undiagnosed cirrhosis. That’s important to be aware of as you’re assessing patients with altered mental status. Look for signs of chronic liver disease that might tip you off to that diagnosis.

Everything we’ve discussed are the important elements of an initial evaluation: ruling out other causes, not necessarily relying on a serum pneumonia level, and going through that checklist of potentially precipitating events. This is probably the most important part of this evaluation because you’ll find a lot of life-threatening diseases that way: serious infections, variceal or other gastrointestinal bleeding, hepatorenal syndrome, significant electrolyte disturbances, even liver cancer, hepatocellular carcinoma. Those can be picked up relatively quickly.

It’s important to initiate treatment early. If those things happened in patients with HE in the emergency department, we’d be in a much better situation nationwide in terms of outcomes, length of stay, and probably readmissions. It seems straightforward when you and I are talking, but it’s tougher in the real world. I can’t imagine how many patients you see during a shift and how many different diseases you encounter. Hopefully, we’re raising some awareness about hepatic encephalopathy, which is an increasingly encountered diagnosis in the hospital.

You’re right. When you talk about the increasing incidences, it’s going to be dramatic, particularly with nonalcoholic steatohepatitis. And obesity is such a challenge in our country; one-third of Americans are not just overweight but obese. This could potentially be a dramatically increasing concern.

It is. I’m sure you’ve encountered what we have, which is that over the past few years with the COVID-19 pandemic, we’ve also seen an increasing number of patients with alcohol-associated cirrhosis and alcoholic hepatitis, both of which can cause hepatic encephalopathy. We’re seeing more sick patients with end-stage-type liver disease. The 2 major drivers of that are fatty liver disease, and there’s quite a bit of alcohol-associated liver disease.

A transplant hepatologist shares advice for emergency department physicians and clinicians to improve the diagnosis and treatment of hepatic encephalopathy.

Strategies for Improving Diagnosis of HE

Particularly in geriatric patients—most of patients with HE [hepatic encephalopathy] are more than 40 years of age, often older than 50—medication reconciliation is key. Fortunately at our facility [Texas Tech University], we have a pharmacist in the emergency department and a pharmacy tech, so any of our admitted patients will have a medication record. I find it astonishing that many patients in the geriatric group will get things such as—I’m not picking on 1 medication in particular, but as a group they have sedating adverse effects—Flexeril for musculoskeletal pain or benzodiazepines and opioids. They all have adverse effects, but these effects are even more pronounced in the geriatric population. You want to avoid that because they not only cause problems such as gait imbalances and increased risks of fall but also challenge things in the setting for hepatic encephalopathy. I agree completely: medication reconciliation is key to minimize meds with any sedating effects.

I’ll add 1 to your list. We see several patients who have been prescribed Ambien or something along those lines. In part, I suspect, that’s because hepatic encephalopathy alters sleep, so patients will often complain that they have insomnia. They might fall asleep during the day, but at night they’re having trouble sleeping. Unfortunately, sleep aids like that can make hepatic encephalopathy worse and potentially lead to an emergency department visit or a hospitalization for an exacerbation of overt hepatic encephalopathy that at the end of the day was related to polypharmacy or medication related.

James Williams, MS, DO, FACEP, provides insight on the importance of medication reconciliation when managing patients with hepatic encephalopathy.

Medication Reconciliation in HE Management

We also look with simple imaging like an ultrasound with doppler for other potentially precipitating factors like a portal vein thrombosis or hepatocellular carcinoma/liver cancer, which might have caused them to decompensate with this episode of encephalopathy. Then in the blood work, it sounds like you’re also interested in hepatorenal syndrome, so even on the basic blood work we can sometimes find other major problems like acute kidney injury or electrolyte derangements. Hyponatremia’s a big one, hypokalemia. Anything else in terms of precipitating factors that you look for? I imagine you look through medications closely.

Well, I’m not sure about your patients, but not all my patients do exactly what we recommend. Medication noncompliance is a challenge. Just last night I saw a patient and she admitted, she said, “I’m a terrible patient. I don’t take any of my antihypertensive or my antidiabetic medications.” So that’s a big problem. To draw another analogy, sometimes it’s like a psychiatric patient; again, I’m talking to my emergency medicine colleagues and the patients feel great, so they stop taking their medication. Well, of course, that’s going to lead unfortunately to a bad outcome. The patients, particularly if they’re only on lactulose, know it’s a terrible medication. They don’t like it. I say that it’s a terrible medication only in so far as that it causes some diarrhea, and the patients don’t like that, so they oftentimes will stop and that’s going to precipitate then another episode of HE [hepatic encephalopathy], and it’s a rapid cycle. That’s what I find so fascinating about these patients, they are complex. It’s not just one simple thing like appendicitis, take it out, and we’re done. One thing leads to another and there are multiple diagnoses at the same time. I’d underscore that one of the benefits I’ve found is that if I can optimize what the therapeutic benefit of these medicines is and then decrease the side effects, then that’s going to lead to patient compliance, and hopefully, that’s going to decrease my re-hospitalization and optimize outcome and minimize mortality and morbidities. That’s a big thing. Just give the patients something that they’re not going hate taking, that will increase their compliance.

Hepatic encephalopathy is unique in some ways because as it gets worse, it’s more likely patients are not going to take their medications, which is too bad. They’re oftentimes patients who have the best of intentions. They can be very compliant and always take their medications, but once they’re altered, that’s one of the first things to go is remembering to take lactulose 3 times a day or taking their rifaximin [Xifaxan] twice a day, and then they all of a sudden can get worse. We see both patients who baseline have trouble adhering to medication requirements or the patients who are very compliant, but because of the condition then run into problems where they're not taking their medications as prescribed or at all. When it comes to medications, another thing that I look for is have they been taking any sedating medications? Sometimes those can be the patient just taking them on their own. They might be taking opioids, benzos [benzodiazepines], or sleep aids, and those may or may not be prescribed for them. Sometimes another physician who’s taking care of them is prescribing that medication for a condition, not necessarily thinking how it might adversely affect their mental status because of their HE.

Arun Jesudian, MD, and James Williams, MS, DO, FACEP, highlight precipitating factors for HE and medication compliance for the condition.

James Williams, MS, DO, FACEP

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