Panelists Discuss Challenges of Diagnosing HE

Pharmacy Practice in Focus: Health SystemsMarch 2019
Volume 8
Issue 2

Experts review the wide spectrum of neuropsychiatric manifestations associated with patients with hepatic encephalopathy.

Hepatic Encephalopathy (he) is an important neuropsychiatric complication of chronic liver disease, resulting in significant morbidity, including altered condition, impaired cognition, and mortality worldwide.1,2

In a recent Peer Exchange video series on, panelists Steven L. Flamm, MD; Arun B. Jesudian, MD; David M. Salerno, PharmD; and Elliot B. Tapper, MD, provided an overview of HE, touching on signs and symptoms as well as risk factors for chronic liver disease (CLD).

At any given time, there are about 600,000 to 1 million individuals living with cirrhosis, and 20% to 80% of patients with cirrhosis experience minimal or covert HE, in which they lack obvious clinical signs of the disorder, according to the panelists.3 Patients with HE accounted for more than 110,000 hospitalizations per year between 2005 and 2009, about 0.33% of hospitalizations in the United States.4

The panelists agreed that scanning for HE signs and symptoms in patients with CLD can be tricky because, as Flamm said, “the majority of patients who have chronic liver disease for many years have no symptoms at all.... Many of these diseases are very serious, and if you wait until patients become symptomatic, it’s often too late to reverse.”

However, there are symptoms to watch for, particularly in patients with advanced disease, including “water in their belly, ascites. [Patients] can develop edema, swelling in their legs. They can develop confusion…hepatic encephalopathy,” Flamm said.

“They can develop large veins in the esophagus, esophageal varices, or gastric varices and bleed,” he said. “There are many different signs and symptoms of advanced liver disease.” Flamm added that it is important to “document in the chart…that their signs and symptoms are so that when you see the patient and when others see the patient in following days, they can get an idea of how the patient is doing. Are they doing worse, or are they doing better? Not just [that] they have HE, [but] what are the issues?... I think it helps you know [whether] the patient is responding to therapy.”

A multipronged approach is most commonly recommended for managing overt HE and consists of “(1) initiating care for patients with altered consciousness, (2) seeking and treating alternative causes of altered mental status, (3) identifying and correcting precipitating factors, and (4) commencing empirical HE treatment.”3

For the last step, the use of nonabsorbable disaccharides such as lactulose is recommended as an initial treatment to reduce ammonia absorption and encourage the growth of beneficial intestinal microorganisms, but poor adherence is common because patients are asked to titrate their doses based on their bowel movements, which can be challenging for those experiencing cognitive impairment. The antibiotic rifaximin has also been shown to help improve symptoms and prolong remission.

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  • Wijdicks EF. Hepatic encephalopathy. N Engl J Med. 2016;375(17):1660-1670. doi: 10.1056/NEJMra1600561.
  • Flamm SL. Complications of cirrhosis in primary care: recognition and management of hepatic encephalopathy. Am J Med Sci. 2018;356(3):296-303. doi: 10.1016/j.amjms.2018.06.008.
  • Vilstrup H, Amodio P, Bajaj J, et al; American Association for the Study of Liver Diseases. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by AASLD and EASL. Published 2014. Accessed November 9, 2018.
  • Stepanova M, Mishra A, Venkatesan C, Younossi ZM. In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009. Clin Gastroenterol Hepatol. 2012;10(9):1034-1041.e1. doi: 10.1016/j.cgh.2012.05.016.

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