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Hernaez R, Li H, Moreau R, Coenraad MJ. Definition, diagnosis and epidemiology of acute-on-chronic liver failure. Liver Int 2023. [PMID: 37424175 DOI: 10.1111/liv.15670] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
This narrative review addresses the definition of acute-on-chronic liver failure, a condition associated with high short-term mortality in patients with chronic liver disease and/or cirrhosis. We provide two major points of view: the East and the West perspective. Both definitions vary regarding the underlying patient population and organ failure(s) definition. Nevertheless, all the definitions have their clinical utility: from the core concept of having the "liver" as a conditio sine qua non, the syndrome cannot exist (Asian Pacific Association for the Study of the Liver); a data-driven, robust definition (European Association for the Study of the Liver); a bedside tool that can quickly identify patients at high risk of dying (North American Consortium for the Study of End-stage Liver Disease [NACSELD]). In each section, we provide the overall definitions, the criteria of organ failure(s), and some epidemiological data illustrating how these apply in each area of the world.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, TX Center, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hai Li
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, France
- INSERM, Université de Paris Cité, Centre de Recherche sur l'Inflammation (CRI), Service d'Hépatologie, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), and Hôpital Beaujon, Clichy, France
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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Bajaj JS, Hassanein TI, Pyrsopoulos NT, Sanyal AJ, Rahimi RS, Heimanson Z, Israel RJ, Rockey DC. Dosing of Rifaximin Soluble Solid Dispersion Tablets in Adults With Cirrhosis: 2 Randomized, Placebo-controlled Trials. Clin Gastroenterol Hepatol 2023; 21:723-731.e9. [PMID: 35750249 DOI: 10.1016/j.cgh.2022.05.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/22/2022] [Accepted: 05/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cirrhosis-related complications are a major burden. Rifaximin soluble solid dispersion (SSD) tablets (immediate-release [IR]; sustained extended-release [SER]) were designed to increase rifaximin water solubility. These analyses evaluate dosing for prevention of cirrhosis complication-related hospitalizations/mortality and overt hepatic encephalopathy (OHE) treatment. METHODS Two phase II, randomized, double-blind, placebo-controlled trials were conducted. Trial 1: outpatients with early decompensated cirrhosis randomized to placebo or rifaximin SSD once-nightly: IR 40 or 80 mg, SER 40 or 80 mg, or IR 80 mg plus SER 80 mg, for 24 weeks. Trial 2: inpatients with OHE randomized to lactulose plus placebo or rifaximin SSD: IR 40 mg once or twice daily or SER 80 mg once or twice daily for ≤14 days. Primary efficacy endpoint: time to cirrhosis complication-related hospitalization/all-cause mortality (Trial 1) or time to OHE resolution (Trial 2). RESULTS In Trial 1 (n = 516), no significant difference in time to cirrhosis complication-related hospitalization/all-cause mortality vs placebo. In a post hoc analysis, time to all-cause hospitalization/all-cause mortality was improved with IR 40 mg vs placebo (15.4% [12/78] vs 27.7% [26/94]; P = .03). A Trial 2 prespecified interim analysis (n = 71) showed lactulose plus rifaximin SSD IR 40 mg bid significantly reduced median time to OHE resolution (21.1 hours) vs lactulose plus placebo (62.7 hours; P = .02). Trial 2 was subsequently terminated. CONCLUSION Rifaximin SSD IR 40 mg may reduce hospitalizations in patients with cirrhosis and shorten duration of OHE during hospitalization-considered a negative finding, yet also hypothesis-generating. (ClinicalTrials.govNCT01904409; NCT03515044).
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, Central Virginia Veterans Affairs Healthcare System, Richmond, Virginia.
| | | | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia
| | - Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
| | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, South Carolina
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García-Martínez R, Diaz-Ruiz R, Poncela M. Management of Hepatic Encephalopathy Associated with Advanced Liver Disease. Clin Drug Investig 2022; 42:5-13. [PMID: 35536537 PMCID: PMC9205788 DOI: 10.1007/s40261-022-01146-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a very prevalent condition in patients with advanced liver disease and has a high recurrence rate. The pathophysiology has a multifactorial origin where hyperammonaemia and inflammation become particularly relevant. There are no HE-specific diagnostic tests, and diagnosis is usually made by taking into account the presence of suggestive and compatible clinical symptoms, the existence of a predisposing liver condition and ruling out other causes with similar clinical manifestations. Once the diagnosis of HE is established, it is essential to carry out an adequate classification based on the underlying liver disease, the intensity of clinical manifestations, the temporal course of the disease and the presence or absence of precipitating factors. Treatment should be aimed at decreasing the duration, intensity and consequences of episodes, preventing recurrence and limiting the impact of the disease in patients and their relatives.
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Affiliation(s)
- Rita García-Martínez
- Department of Internal Medicine, Gregorio Marañon University General Hospital, 28007, Madrid, Spain.
- School of Medicine, Complutense University Madrid, Madrid, Spain.
- Online Center for Biomedical Research of Hepatic and Digestive Diseases (CIBEREHD), Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle del Doctor Esquerdo, 46, 28007, Madrid, Spain.
| | - Raquel Diaz-Ruiz
- Department of Digestive Diseases, Gregorio Marañon University General Hospital, 28007, Madrid, Spain
| | - Marta Poncela
- Department of Digestive Diseases, Gregorio Marañon University General Hospital, 28007, Madrid, Spain
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Bass NM. A Brief History of Hepatic Encephalopathy. Clin Liver Dis (Hoboken) 2021; 18:49-62. [PMID: 34745583 PMCID: PMC8555462 DOI: 10.1002/cld.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Audio Recording.
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Affiliation(s)
- Nathan M. Bass
- Department of MedicineUniversity of California, San FranciscoSan FranciscoCA
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5
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Teh KB, Loo JH, Tam YC, Wong YJ. Efficacy and safety of albumin infusion for overt hepatic encephalopathy: A systematic review and meta-analysis. Dig Liver Dis 2021; 53:817-823. [PMID: 34011479 DOI: 10.1016/j.dld.2021.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The efficacy and safety of albumin infusion for treatment and prevention of overt hepatic encephalopathy (OHE) among cirrhosis patients remained controversial. We performed a systematic review and meta-analysis to evaluate the benefit of albumin infusion for the treatment and prevention of OHE. METHODS We performed a systematic search of 4 electronic databases up to 31st January 2021. The primary outcome was the resolution of OHE. Secondary outcomes were inpatient mortality and albumin-associated adverse events. We assessed the pooled odds' risk, pooled mean differences, 95% confidence interval and heterogeneity using Review Manager Version 5.3. RESULTS A total of 12 studies (2,087 subjects) were identified. Among cirrhosis patients with OHE, albumin infusion was associated with a lower pooled risk of OHE (OR=0.43, 95%CI: 0.27, 0.68; I2=0%). Among patients without baseline OHE, albumin infusion was associated with a lower pooled risk of developing OHE (OR=0.53, 95%CI: 0.32, 0.86; I2=62%). Albumin infusion was associated with a lower pooled risk of inpatient mortality (OR=0.36, 95%CI: 0.21, 0.60; I2=0%). CONCLUSION Well-powered randomized trials are required to confirm the benefits of albumin infusion for the prevention and treatment of overt hepatic encephalopathy among decompensated cirrhosis patients.
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Affiliation(s)
- Kok Ban Teh
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yew Chong Tam
- Department of Medicine, Singapore General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Duke-NUS Academic Medicine Programme, Singhealth, Singapore.
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Rose CF, Amodio P, Bajaj JS, Dhiman RK, Montagnese S, Taylor-Robinson SD, Vilstrup H, Jalan R. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol 2020; 73:1526-1547. [PMID: 33097308 DOI: 10.1016/j.jhep.2020.07.013] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and serious complication of both chronic liver disease and acute liver failure. HE manifests as a wide spectrum of neuropsychiatric abnormalities, from subclinical changes (mild cognitive impairment) to marked disorientation, confusion and coma. The clinical and economic burden of HE is considerable, and it contributes greatly to impaired quality of life, morbidity and mortality. This review will critically discuss the latest classification of HE, as well as the pathogenesis and pathophysiological pathways underlying the neurological decline in patients with end-stage liver disease. In addition, management strategies, diagnostic approaches, currently available therapeutic options and novel treatment strategies are discussed.
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Affiliation(s)
- Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada.
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Simon D Taylor-Robinson
- Department of Surgery and Cancer, St. Mary's Hospital Campus, Imperial College London, London, United Kingdom
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
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Chautant F, Guillaume M, Robic MA, Cadranel JF, Peron JM, Lison H, Cool C, Bureau C, Duhalde V. Lessons from “real life experience” of rifaximin use in the management of recurrent hepatic encephalopathy. World J Hepatol 2020; 12:10-20. [PMID: 31984117 PMCID: PMC6946626 DOI: 10.4254/wjh.v12.i1.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/30/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a major complication of cirrhosis with independent prognostic significance. The current management of HE is mainly based on lactulose. Rifaximin has been shown to decrease the risk of HE recurrence in patients with episodic forms. HE can also be persistent. However, there is no drug support recommendation for rifaximin use in this setting.
AIM To assess the effectiveness of rifaximin in the management of recurrent episodes of HE and recurrent acute exacerbations on persistent HE, in “real life conditions”.
METHODS In this retrospective study, using a within-subjects design, we collected data of patients treated with rifaximin for HE in two liver diseases centers, during the six-month period before and during the six-month period after the initiation of rifaximin. The primary effectiveness endpoint was the total number of HE events involving hospitalization.
RESULTS Rifaximin was introduced for prevention of recurrent HE episodes in 29 out of 62 patients with normal mental status between episodes and for prevention of recurrent acute exacerbations on persistent HE in 33 out of 62 patients. In the “prevention of recurrent HE episodes” group, fewer HE events (0.79 vs 1.78; P = 0.013) were reported during the period of time when rifaximin was used. In the “prevention of recurrent acute exacerbations on persistent HE” group, there was no significant difference in the number of HE-events (1.48 vs 1.77; P = 0.582).
CONCLUSION In this real-life experience, the effectiveness of rifaximin was confirmed in the prevention of HE episodes recurrence but was not proved in the prevention of acute exacerbations recurrence on persistent HE.
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Affiliation(s)
- Fiona Chautant
- Service Pharmacie, Centre Hospitalier Universitaire de Toulouse, Hôpital Paule de Viguier, Toulouse 31059, France
| | - Maeva Guillaume
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Marie-Angèle Robic
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | | | - Jean-Marie Peron
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Hortensia Lison
- Department of Hepato-Gastroenterology, Laennec Hospital, Creil 60109, France
| | - Charlène Cool
- Department of Pharmacy and UMR INSERM 1027, University Hospital, Toulouse 31059, France
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Véronique Duhalde
- Department of Pharmacy, University Hospital Toulouse, Toulouse 31059, France
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8
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Tapper EB. Predicting Overt Hepatic Encephalopathy for the Population With Cirrhosis. Hepatology 2019; 70:403-409. [PMID: 30703852 PMCID: PMC6597301 DOI: 10.1002/hep.30533] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/25/2019] [Indexed: 12/20/2022]
Abstract
Hepatic encephalopathy (HE) is associated with poor quality of life, sharply increased mortality, repeated hospitalizations, falls, and motor vehicle accidents. HE manifests with a dynamic spectrum of severity. Overt HE is clinically obvious disorientation, even coma. Although multiple strategies are available to characterize early-stage HE, data are limited that validate these methods in predicting overt HE, many are impractical in clinical practice, and test cutoffs relevant to the average patient clinicians manage are lacking. To accurately and efficiently classify the risk of overt HE in the population with cirrhosis, novel strategies may be needed. Herein, we review the potential competing strategies for the prediction of overt HE. Conclusion: We propose refining diagnostic cutoffs for tests that are designed to define early HE, using overt HE as a gold standard and expanding prediction tools by using measures of components from the risk pathway for HE.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor
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Allampati SK, Mullen KD. Understanding the impact of neurologic complications in patients with cirrhosis. SAGE Open Med 2019; 7:2050312119832090. [PMID: 30834114 PMCID: PMC6396044 DOI: 10.1177/2050312119832090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.
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Affiliation(s)
- Sanath K Allampati
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kevin D Mullen
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
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10
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Amodio P. Current Diagnosis and Classification of Hepatic Encephalopathy. J Clin Exp Hepatol 2018; 8:432-437. [PMID: 30564001 PMCID: PMC6286442 DOI: 10.1016/j.jceh.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy is a brain dysfunction caused by liver insufficiency and/or portal-systemic shunt; it manifests as a wide spectrum of neurological or psychiatric abnormalities ranging from subclinical alterations to coma. It should be differentiated from other neurological/psychiatric disorders that can occur in patients with liver disease. Its classification needs to take into account the underlying condition, severity, course, precipitating factors, and-possibly-sensitivity to ammonia-lowering agents.
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Affiliation(s)
- Piero Amodio
- Address for correspondence: Piero Amodio, MD, FRCP, Department of Medicine –DIMED- University of Padova, via Giustiniani, 2, 35128 Padova, Italy. Fax: +39 049 7960903.
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Flamm SL. Complications of Cirrhosis in Primary Care: Recognition and Management of Hepatic Encephalopathy. Am J Med Sci 2018; 356:296-303. [PMID: 30286824 DOI: 10.1016/j.amjms.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/24/2018] [Accepted: 06/08/2018] [Indexed: 12/13/2022]
Abstract
Approximately 3.7% of patients in primary care settings have chronic liver disease, and 18% with chronic liver disease in the specialty care setting have cirrhosis. For cirrhotic patients without complications, prognosis is generally favorable; increased morbidity and mortality are observed when complications (i.e., hepatic encephalopathy [HE]) occur. HE occurs in up to 70% of patients with cirrhosis. Neurologic signs in HE span a wide spectrum, from those not easily apparent (covert) to more clinically obvious signs (overt). Providers should consider overt HE in patients with cirrhosis and signs of impaired cognition, confusion, consciousness and/or personality changes, and/or impaired memory. Overt HE treatment includes identifying and treating precipitating factors and reducing bacterial-derived toxin loads. For acute overt HE, lactulose is first-line treatment. To prevent HE recurrence, lactulose plus rifaximin is recommended. Patients with cirrhosis and HE often present in primary care; recognizing and properly managing HE are important in this setting.
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Affiliation(s)
- Steven L Flamm
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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12
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Reuter B, Walter K, Bissonnette J, Leise MD, Lai J, Tandon P, Kamath PS, Biggins SW, Rose CF, Wade JB, Bajaj JS. Assessment of the spectrum of hepatic encephalopathy: A multicenter study. Liver Transpl 2018; 24:587-594. [PMID: 29457869 PMCID: PMC5912984 DOI: 10.1002/lt.25032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/02/2018] [Accepted: 02/07/2018] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.
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Affiliation(s)
- Bradley Reuter
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
| | | | | | | | - Jennifer Lai
- University of California, San Francisco, CA, USA
| | | | | | | | | | - James B Wade
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
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Garrido M, Turco M, Formentin C, Corrias M, De Rui M, Montagnese S, Amodio P. An educational tool for the prophylaxis of hepatic encephalopathy. BMJ Open Gastroenterol 2017; 4:e000161. [PMID: 28944074 PMCID: PMC5596837 DOI: 10.1136/bmjgast-2017-000161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/16/2017] [Accepted: 07/25/2017] [Indexed: 01/25/2023] Open
Abstract
Background Providing structured information for the understanding of hepatic encephalopathy (HE) might be relevant to the prevention and management of the syndrome. The aim of our study was to design a brief, structured educational intervention and evaluate its usefulness in preventing HE-related hospitalisation over time. Methods Thirty-nine cirrhotic outpatients with a history of HE were enrolled and randomly assigned to an intervention (group A; n=20) or control group (group B; n=19). All of them underwent evaluation of HE (clinical and quantitative neuropsychiatric assessment) and completed the Questionnaire on the Awareness of Encephalopathy. A 15 min educational session was then provided to patients in group A, including basic information on the pathophysiology, hygienic and medical management of HE. Results No demographic/clinical differences were observed at baseline between the two groups. Similarly, there were no significant differences in HE-related information available at baseline between the two groups; knowledge of HE was limited in both. The intervention was highly effective in increasing patients’ understanding of treatment of the condition (from 5% to 80%). The educational intervention also reduced the risk of developing an episode of HE over a period of 12 months. Conclusion The educational intervention confirmed the poor knowledge of patients with previous HE about their condition, served as a tool to increase patients’ awareness, and minimised HE-related readmission rates over a period of 1 year.
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Affiliation(s)
- Maria Garrido
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Matteo Turco
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Chiara Formentin
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Michela Corrias
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Michele De Rui
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Piero Amodio
- Department of Medicine, DIMED, University of Padova, Padova, Italy
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Bajaj JS. Introduction and setting the scene: New nomenclature of hepatic encephalopathy and American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines. Clin Liver Dis (Hoboken) 2017; 9:48-51. [PMID: 30992956 PMCID: PMC6467136 DOI: 10.1002/cld.610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/02/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and McGuire VA Medical CenterRichmondVA
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