Telltale Signs of Hepatic Encephalopathy: Improving Diagnosis in In-Patient Setting - Episode 1
James Williams, MS, DO, FACEP, describes the presentation of hepatic encephalopathy (HE) in patients and challenges associated with diagnosis.
Arun Jesudian, MD: Hello, and welcome to this HCPLive® Peers & Perspectives® titled “Telltale Signs of Hepatic Encephalopathy: Improving Diagnosis in the Inpatient Setting.” I’m Dr Arun Jesudian, I’m a transplant hepatologist and an associate professor of clinical medicine at Weill Cornell Medicine in New York, New York. Joining me is 1 of my colleagues, Dr James Williams. Jim, please introduce yourself.
James Williams, DO, MS, FACEP: Thanks for letting me join you. My name is Jim Williams. I’m a clinical professor of emergency medicine at Texas Tech University [Health Sciences School of Medicine], and I’m the research chair at Meritus Medical Center and president-elect of Emergency Medicine Foundation.
Arun Jesudian, MD: Thanks for joining, Jim. Today we’re going to highlight characteristics that put hospitalized patients at higher risk for developing hepatic encephalopathy [HE]. We will share suggestions for monitoring hospitalized patients and how proper discharge planning and transition of care can reduce the risk of rehospitalization for HE. Let’s get started on our first topic. Jim, when you see patients with hepatic encephalopathy in the emergency department, how do they usually present? What tips you off that they might have that disorder?
James Williams, DO, MS, FACEP: That’s part of the challenge. We don’t know our patients prior to them coming in, and the difference was large. If a patient comes in with an altered mental status, whether it’s subtle or pronounced, we have to consider hepatic encephalopathy. That has a very broad difference and work-up. The main thing is to consider the diagnosis of somebody coming in who has altered mental status.
Arun Jesudian, MD: Absolutely. It’s probably helpful for the viewers to conceptualize what these patients are like. Those who are most at risk of hepatic encephalopathy are patients with decompensated cirrhosis. When you see a patient, do you have a sense of whether they have decompensated cirrhosis even before you’ve assessed their mental status? What do you look for in that situation?
James Williams, DO, MS, FACEP: Like any of the diseases, there’s a broad spectrum of presentation. It’s easier for us is if the patient comes in and is yellow with a huge, bloated abdomen. That’s 1 tip-off that might lead me to think that’s a hepatic encephalopathy. But that’s a minority of patients. At that point, they’re declared and usually in a well-controlled environment, though at times they may not be compliant with their medications. This leads them to fall off the curve. On the other end of the spectrum, it’s a key thing if patients are able to tell us they’ve had a history of liver failure or hepatic encephalopathy. In the emergency department it’s challenging because often patients come in by themselves through EMS [emergency medical services], so there’s no history.
A classic example is if EMS brings somebody in as a code stroke because they have altered mental status. They’re altered and disoriented and no one else is here to clarify any history. You must avoid going down a rabbit hole. A distinction is you want to have a broad differential, so you can consider stroke but also hepatic encephalopathy, electrolyte arrangements, sepsis, and a host of other issues going on with these patients.
Arun Jesudian, MD: It’s important to have a broad differential diagnosis for their altered mental status. In my practice, I take care of a lot of patients with cirrhosis. Often the patients at risk of hepatic encephalopathy have clinically significant portal hypertension. They often have ascites, and they may have prominent abdominal vessels. They may have a history of variceal bleeding. They could have jaundice if their liver function is poor and they’re not conjugating and excreting bilirubin. A patient with altered mental status should trigger alarm bells for hepatic encephalopathy, at least among the differential diagnosis. One thing that’s important to point to is that within HE there’s covert or subtle HE, but I don’t think that’s what you’re mainly seeing in the emergency department. You’re seeing more of the overt HE. How are those patients in terms of mental status when you see them? I imagine it’s a spectrum of how much they’re altered.
James Williams, DO, MS, FACEP: That’s the challenge. The other point I wanted to mention is that it’s not always a singular diagnosis. In medicine, we often think there’s 1 unifying diagnosis that explains everything. But patients with liver failure are very complex. Often, it’s not just 1 but 2 or more primary diagnoses. For example, the patient could come in with a septic situation. That’s what then precipitated hepatic encephalopathy. They come in with electrolyte arrangements and have hepatic encephalopathy because they’re not taking their medications, so they’re going down the road of developing hepatic encephalopathy.
Getting back to your original question, some of the tip-offs are in the history of the patient, to the extent I have it in my prior medical records. If we have any history that the patient has been to our system before we can pull that up, a physical exam gives some clues. Usually it’s lab testing, which isn’t necessary for hepatic encephalopathy but often will exclude other things that are considered in the differential. That’s another way to lead us down the path of correctly diagnosing and treating patients.
Transcript edited for clarity