Hepatic encephalopathy for the hospitalist

Abstract

The care of patients with advanced liver disease is often complicated by episodes of acute decline in alertness and cognition, termed hepatic encephalopathy (HE). Hospitalists must be familiar with HE, as it is a common reason for hospitalization in this population and is associated with significantly increased mortality. This narrative review addresses common issues related to diagnosis and classification, precipitants, inpatient management, and transitions of care for patients with HE. The initial presentation can be variable, and HE remains a clinical diagnosis. The spectrum of HE manifestations spans from mild, subclinical cognitive deficits to overt coma. The West Haven scoring system is the most widely used classification system for HE. Various metabolic insults may precipitate HE, and providers must specifically seek to rule out infection and bleeding in cirrhotic patients presenting with altered cognition. This is consistent with the 4-pronged approach of the American Association for the Study of Liver Disease practice guidelines. Patients with HE are typically treated primarily with nonabsorbable disaccharide laxatives, often with adjunctive rifaximin. The evidence for these agents is discussed, and available support for other treatment options is presented. Management issues relevant to general hospitalists include those related to acute pain management, decisional capacity, and HE following transjugular intrahepatic portosystemic shunt placement. These issues are examined individually. Reversible impairment of brain function in the setting of cirrhosis defines hepatic encephalopathy (HE). HE is associated with significantly decreased survival, 1 and patients with HE have poor outcomes whether HE occurs in isolation or in conjunction with acuteon-chronic liver failure. 2 A large multicenter study comparing cirrhotics with and without HE also found that those with a history of HE were hospitalized more frequently. 2 The presentation of HE is variable, and diagnosis remains clinical. Subtle manifestations of HE persist between episodes, even if gross cognitive function normalizes. 3 Retrospective data suggest the effects of serial bouts of HE may be cumulative, because even with appropriate treatment, the severity of impairment correlates with the number of prior episodes. 3 Even minimal manifestations of hepatic encephalopathy correlate with reduced quality of life. 4 The West Haven score is the most validated scoring system. 5 Higher grades of HE correlate with significantly increased mortality, 2 but due to difficulties differentiating stages 0 and 1, these criteria remain somewhat controversial. The Spectrum of Neurocognitive Impairment in Cirrhosis (SONIC) has been proposed as an alternate conceptualization of HE as a continuous spectrum rather than discrete stages. 6 Table 1 shows findings associated with various West Haven and SONIC stages. Both systems include covert and overt encephalopathy. Covert correlates with West Haven grades 0 to 1, and consists mainly of subtle findings that require spec...