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Dr. Flamm:
This is CE on ReachMD, and I'm Dr. Steven Flamm from Rush University in Chicago.

What things push a patient over the edge from minimal to overt hepatic encephalopathy? And by that, I mean what triggers bring about clear signs of minimal HE progressing to overt HE?

Well, first of all, it's important to know that a patient has cirrhosis and portal hypertension that you as a provider suspect encephalopathy. Second, it's important to know that encephalopathy represents a wide spectrum of cognition issues that patients with portal hypertension have. And it can range from very mild symptoms to very severe.

Of course, it's more difficult to diagnose the ones with mild symptoms because they overlap with other things—fatigue, sleep disturbance, concentration, and short-term memory issues. But you as a provider can help these patients, because if you identify encephalopathy, not only can you treat it, but you can try to identify the provocations that cause it. And in the end, you can help patients’ quality of life and reduce hospital admissions by taking care of this major problem or certainly referring them to a gastroenterologist or hepatologist who will treat it, if you aren't the primary provider that treats the patient.

Now, what are the provocations of encephalopathy? Well, there are many, and they're very common. Dehydration is the most common. Patients with chronic liver disease are often on diuretics for edema or ascites, or both. And when they are on diuretics, they can get subtle dehydration, and that can be manifest by electrolyte abnormalities or subtle renal insufficiency. So reduce diuretics in those patients, even if they're overhydrated.

Next, infections can cause it—urinary tract infection, cellulitis. Identify them if patients have encephalopathy. Upper GI bleeding, that's not hard to miss. Or patients that are overmedicated, particularly with medicines that have neuropsychiatric effects like antihistamines and sleeping pills and antidepressants and anxiety agents and narcotics for pain. Identify these and try to fix the problem. And then, of course, treat patients with ammonia-lowering agents like lactulose and rifaximin.

These all will help patients be appropriately treated for encephalopathy and prevent them from moving forward from minimal encephalopathy to overt encephalopathy.

Don't miss this diagnosis. It's very important for patients, their quality of life, and to reduce their hospitalizations.

I hope you found this information as useful as it was brief. Thanks for listening.

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