Telltale Signs of Hepatic Encephalopathy: Improving Diagnosis in In-Patient Setting - Episode 2
Drs Arun Jesudian and James Williams share thoughts on patients with hepatic encephalopathy who are at risk of hospitalization, poorer patient and economic outcomes associated with readmission rates, and the impact of hepatic encephalopathy on quality of life.
Arun Jesudian, MD: Give us a sense of how often these patients are admitted. When you assess someone and you think this is a patient with cirrhosis who has HE [hepatic encephalopathy], how often do they end up staying in the hospital?
James Williams, DO, MS, FACEP: Most of the time they are admitted. It’s rare for the patient to be discharged. These patients are complicated because of their comorbidities. It’s not common that I can turn them around quickly, whether it’s an electrolyte derangement, a volume problem, or a urea problem. They’re going to be brought in for observation…to turn them around a little. That’s why it’s so important to underscore the early treatment of these patients, so I can then identify and treat them early and get them out earlier. Hopefully, we can get them to you, so they know how to manage their circumstance and avoid readmission. That in and of itself is associated with increased morbidity and mortality.
Arun Jesudian, MD: You’re absolutely right that most of these patients get admitted in part because they’re a vulnerable population. They’re sick in general, having decompensated cirrhosis. Especially presenting with HE, which is often a sign of something more serious going on—infections, bleeding, hepatorenal syndrome, electrolyte disturbances. All of those require an inpatient admission, an assessment, and treatment of a number of complications related to their cirrhosis.
You’re right about readmissions. When we’re able to stabilize and treat their acute medical conditions and discharge them, a large percentage—depending on the studies you look at, 30% to 50%—are back in the hospital within 30, 60, or 90 days. HE admission is unfortunately often followed by a readmission. You touched on some of the problems related to that. Patient outcomes are much poorer when they’re readmitted within 30 days. We spend a lot of health care dollars on these type of admissions. They’re usually long, and they often require ICU [intensive care unit]–level care or other expensive interventions. We’re always looking for ways to prevent unnecessary readmissions when we can.
Another cost that we underestimate is the quality of life and that of the patient and their caregivers. Is this something you’ve seen firsthand in the emergency department?
James Williams, DO, MS, FACEP: We hear that from family members when they bring them in. Often, it will be a protracted conversation or an argument: “Look, you need to go into the hospital. You’re not feeling so well.” It’s absolutely exhausting for the care providers because the patients aren’t acting rationally even when it’s a relatively subtle hepatic encephalopathy, and when it gets worse, it’s more challenging. You’re exactly right: the caregivers are exhausted. It’s tough to get these patients in because they don’t have a cogent thought process. That exacerbates this cascade of other comorbidities that the patient is having. If they have diabetes, their sugars are out of whack, they have incredible fluid shifts, their electrolyte arrangements are terrible, and of course they’re at risk for infections. So, you’re exactly right: it is a huge challenge.
Arun Jesudian, MD: It is, and it’s important for us to take care of the patients holistically—treat all their medical problems but also try to focus on their well-being. From our end, we engage their caregivers, both in helping the patient in terms of their HE diagnosis but also in assessing their needs and whether they’re burning out as a caregiver. It’s tough to take care of a loved one who has this condition that requires them to be hospitalized or come to the emergency department with an altered mental status.
Transcript edited for clarity