Importance of Early Recognition and Treatment of Hepatic Encephalopathy - Episode 1
Arun B. Jesudian, MD, and Kimberly A. Brown, MD, provide an overview of hepatic encephalopathy, signs and symptoms, and underlying liver disease as a major risk factor.
Arun B. Jesudian, MD: Hello and welcome to this Peers & Perspectives® program entitled, “Importance of Early Recognition and Treatment of Hepatic Encephalopathy.” I’m Dr Arun Jesudian, a transplant hepatologist and an associate professor of clinical medicine at Weill Cornell Medicine in New York, New York. Joining me in this discussion is my colleague Dr Kimberly Brown, who is the chief of the division of gastroenterology and hepatology, as well as the associate medical director of the Henry Ford Hospital Transplant Institute in Detroit, Michigan.
Today, we are going to discuss hepatic encephalopathy, or HE, factors that put patients with liver diseases at higher risk of developing HE, and the importance of early recognition and treatment. We will also share our thoughts on using a holistic approach for treating patients with liver diseases. Let’s get started on the first topic. Dr Brown, if you don’t mind, give us some background in terms of what is hepatic encephalopathy, and what sort of signs and symptoms do patients experience?
Kimberly A. Brown, MD: It’s a great question, Arun. The signs and symptoms of encephalopathy can range anywhere from subtle to pretty overt. It occurs in the setting of advanced liver disease, and as patients develop advanced liver disease, as you know, they develop increased pressures within the abdomen, portal hypertension. What happens is blood begins to shunt around that liver, gets back to the heart and then to the brain, and can cause confusion. I think one of the struggles we have with encephalopathy is oftentimes patients and clinicians don’t recognize the underlying liver disease. They don’t understand the cirrhosis, and so they don’t know they’re at risk.
Early subtle signs [of HE] in my practice are altered sleep-wake cycle, tremor, and fatigue. Sometimes, patients themselves will recognize that they can’t do calculations very efficiently. They might have some memory disorder. And it can range all the way to coma and anything in between. I think part of the issue we have is just recognizing the underlying liver disease. And that’s the patient who’s at risk of developing this at some point in the future.
Arun B. Jesudian, MD: Absolutely, and it’s an important point, recognizing that advanced liver disease is the major risk factor for HE. If you talk to primary care providers, what might you tell them about which patients they should be screening for HE? For example, patients will often have ascites because portal hypertension is usually the prerequisite to that portosystemic shunting. Sometimes we might say signs include jaundice or edema. What type of patient could you tell a primary care provider to look at in particular for the presence of HE based on other signs and symptoms they might have?
Kimberly A. Brown, MD: It’s a great point. Certainly I would say to primary care clinicians, if they have anyone in their practice with known cirrhosis, that is a patient they need to screen. But if they have a patient who has liver disease and lower extremity edema, or ascites, or if they’ve had an endoscopy showing varices, or probably one of the most critical pieces of information they would have at their disposal is the platelet count. If somebody has a platelet count below 120,000, they very likely have portal hypertension, if they have underlying liver disease as the cause of that. Those are the patients I think we need to be keyed into.
Arun B. Jesudian, MD: It’s a great point because the CBC [complete blood count] is such a routine laboratory test that we get, but oftentimes we might be too focused on the liver panel and not the thrombocytopenia, which is your big tip-off for the presence of clinically significant portal hypertension.
Kimberly A. Brown, MD: Exactly, yes.
Transcript edited for clarity