Telltale Signs of Hepatic Encephalopathy: Improving Diagnosis in In-Patient Setting - Episode 4
Dr James Williams shares insight on factors leading to delays in hepatic encephalopathy (HE) diagnosis, the importance of early detection, and strategies to improve diagnosis in the in-patient setting.
Arun Jesudian, MD: In your experience, do you find that sometimes there’s a delay, even an unnecessary delay, in making that diagnosis and treating HE [hepatic encephalopathy]?
James Williams, DO, MS, FACEP: There is. It goes back to that unifying diagnosis, and we’re all taught that there’s 1 unifying diagnosis. Uniquely in these patients, but also in other patients we’re seeing, they’re so complex, there’s often more than 1 diagnosis. It is itchy, but they could have a UTI [urinary tract infection] with sepsis. That precipitates things. You always have to consider it. The other thing we fight against is anchoring bias in our diagnosis. If you think they have a UTI and sepsis, or that they have spontaneous bacterial peritonitis and sepsis; that’s got to be the cause. It’s also a challenge knowing that serum ammonia is unreliable. One of the key things in understanding HE is No. 1, I’ve got to make the diagnosis, and No. 2, I don’t need a serum ammonia level to make the diagnosis. Most important is that if I don’t treat it, that patient’s morbidity and mortality is arguably going to be worse. That lowers my threshold for being aggressive in treating HE even if there are other primary diagnoses, because you know their outcomes is poor if it goes neglected.
Arun Jesudian, MD: I couldn’t agree with you more about the importance of diagnosing HE earlier, or at least keeping it in your differential and treating it early, because of the implications that has on the patient’s outcome. This includes hospitalization—the duration, the length of stay, and potentially their risk of being readmitted. In this day and age, because we’re seeing more patients cirrhosis in our hospitals, it’s important to keep that in mind in front of all comers in the emergency department. It’s not always as clear a diagnosis as, say, a CHF [congestive heart failure] exacerbation, but it’s becoming more common. There are at least 600,000 patients with cirrhosis in the United States. It’s the 11th leading cause of death. It will be a disease that all inpatient providers are going to see with increasing frequency. If they approach it the way you suggested, then we’re going to miss that diagnosis less, make it earlier, and impact treatment outcomes in the hospital for patients with cirrhosis and hepatic encephalopathy. Do you have any other suggestions for how to make the diagnosis or how to treat these patients early on in their presentation in the hospital?
James Williams, DO, MS, FACEP: One thing that’s important, particularly in the emergency department, is that we have an incredible challenge with boarding. That means that a patient is technically accepted as an admission to the hospital, but physically they’re still in the emergency department. Our mindset in the emergency department is to treat it and then hand off to you or the hospitalist and admitting service, not to think of it again. But if the patient is still in the emergency department, even if it’s for 4, 6, or 12 hours—oftentimes it goes beyond that—the aggressive treatment may not be started as early as it would be if they were upstairs on a floor. The hospital isn’t seeing them in the emergency department, so there might be some delay in care. I’d implore my colleagues to at least consider hepatic encephalopathy and early and aggressive treatment.
Emergency physicians might not think about HE. They’ll think, “We’ll just give them some lactulose.” But I don’t want to give them lactulose because my nurses will get mad at me if I do that in the emergency department knowing that they’re going to be there for a prolonged period of time. That’s 1 of the benefits of rifaximin if they can take something orally, just to get something treated quickly. I’ll use the analogy of a paradigm. If somebody comes in with sepsis, we’re graded on how fast we get the antibiotics in. It has to be fast. The reason is that if I initiate treatment and can intervene in a disease process earlier, then that disease progression is going to be minimized. The same can be said for a hepatic encephalopathy. It’s important to start the treatment earlier. It makes no sense to say, “They’ll do it upstairs.” Frankly, I don’t know how long that’s going to be. It might be 6 or 12 hours, or it might be more. So I start the treatment earlier, just as I would for any other treatment.
Arun Jesudian, MD: It makes me happy to hear you say that because this is a focus of our efforts when it comes to hepatologists, who end up consulting on these patients, or gastroenterologists. We’re usually saying that we should make this diagnosis early and treat it early so that we can potentially get the patient home sooner, or at least prevent them from having an adverse outcome if possible.
Transcript Edited for Clarity