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Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
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Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Ehrenbauer AF, Schneider H, Stockhoff L, Tiede A, Lorenz C, Dirks M, Witt J, Gabriel MM, Wedemeyer H, Hinrichs JB, Weissenborn K, Maasoumy B. Predicting overt hepatic encephalopathy after TIPS: Value of three minimal hepatic encephalopathy tests. JHEP Rep 2023; 5:100829. [PMID: 37600959 PMCID: PMC10432804 DOI: 10.1016/j.jhepr.2023.100829] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background & Aims Hepatic encephalopathy (HE) is a frequent and severe complication in patients after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for post-TIPS HE remain poorly defined. Minimal HE (mHE) is a well-known risk factor for overt HE in patients with cirrhosis without TIPS. We aimed to evaluate three tools frequently used for diagnosing mHE for their dynamic changes and their predictive value for overt HE after TIPS. Methods We prospectively recruited 84 consecutive patients before TIPS insertion and monitored them for 180 days for post-TIPS HE. Before TIPS insertion, the patients underwent the portosystemic encephalopathy (PSE) syndrome test, the animal naming test (ANT), and the critical flicker frequency (CFF). Patients were retested after TIPS insertion. Results The majority of patients were male (67.9%), and the predominant indication for TIPS was refractory ascites (75%). Median age was 59 years, model for end-stage liver disease score was 12, and 66.3%, 64.6%, and 28.4% patients had evidence for mHE according to the PSE syndrome test, ANT, and CFF, respectively. Overall, 25 patients developed post-TIPS HE within 180 days after TIPS insertion. Post-TIPS incidence of overt HE was 22.2, 28.6, 45.5, and 55.6% in those with no, one, two, and three pathological tests at baseline, respectively. However, none of the three tests was significantly associated with post-TIPS HE. Of note, mean performance in all tests remained stable over time after TIPS insertion. Conclusions PSE syndrome test, ANT and CFF, which are frequently used for diagnosing mHE have limited value for predicting HE after TIPS insertion. We could not find evidence that TIPS insertion leads to a psychometric decline in the long term. Impact and implications This prospective observational study compared three diagnostic tests for mHE and showed the limited value of these tests for predicting overt HE in patients with cirrhosis undergoing TIPS insertion. In addition, the results suggest that cognitive performance generally remains stable after TIPS insertion. These results are important for physicians and researchers involved in the management of patients with cirrhosis undergoing TIPS procedures. The study's findings serve as a starting point for further investigations on the development of more effective strategies for predicting and managing post-TIPS HE. Clinical trial number ClinicalTrials.gov NCT04801290.
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Affiliation(s)
- Alena F. Ehrenbauer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hannah Schneider
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lena Stockhoff
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Anja Tiede
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Charlotte Lorenz
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Jennifer Witt
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
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Trebicka J. Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close? J Hepatol 2017; 66:442-450. [PMID: 27984174 DOI: 10.1016/j.jhep.2016.10.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/22/2016] [Accepted: 10/23/2016] [Indexed: 12/14/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis such as variceal bleeding and refractory ascites, but it also bears the risk of liver failure, overt hepatic encephalopathy (HE) and cardiac decompensation. Variceal bleeding may be controlled using endoscopic and medical treatment in patients with compensated cirrhosis; in decompensated patients, however, TIPS improves survival. Therefore, an early TIPS (within 72h or if later, still early after bleeding) might improve the survival of patients by preventing an inflammatory response and bacterial translocation. Both these processes mediate an impaired immunological and hemodynamic response, thereby facilitating the development of acute-on-chronic liver failure (ACLF) and/or death. Similarly, in patients with refractory ascites, TIPS should be used early in treatment to prevent acute kidney injury (AKI) and hepatorenal syndrome (HRS) after precipitating events induced by complications of portal hypertension. Whether TIPS and/or embolization should be used to treat portal vein thrombosis and spontaneous shunts is still a matter of debate and should be further investigated. In summary, the careful selection of patients for TIPS is crucial. New biomarkers, especially those evaluating systemic inflammation and bacterial translocation, might improve the predictive value of established clinical parameters such as bilirubin and overt HE. However, a significant amount of further research must be carried out.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; Institute of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
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Brenner M, Butz M, May ES, Kahlbrock N, Kircheis G, Häussinger D, Schnitzler A. Patients with manifest hepatic encephalopathy can reveal impaired thermal perception. Acta Neurol Scand 2015; 132:156-63. [PMID: 25630844 DOI: 10.1111/ane.12376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Previous evoked potential studies indicated central impairments of somatosensory function in patients suffering from hepatic encephalopathy (HE). The aim of this study was to quantify the somatosensory perception in patients with minimal and overt HE. MATERIALS AND METHODS Forty-two patients with liver cirrhosis and HE up to grade 2 and 12 age-matched healthy controls underwent a comprehensive graduation of HE including the West Haven criteria, the critical flicker frequency (CFF), and neuropsychometric testing. Quantitative sensory testing, standardized by the German Research Network on Neuropathic Pain, was performed on both hands. RESULTS Pain and mechanical detection thresholds were unchanged in HE. Tests of thermal processing revealed that patients with HE of grade 2 perceive cold at lower temperatures (cold detection threshold) and need a higher temperature difference to distinguish between warm and cold (thermal sensory limen). These impairments correlated with the CFF. A correction for attention deficits by performing partial correlations using neuropsychometric test results canceled these correlations. CONCLUSIONS The present findings demonstrate an impairment of temperature perception in HE. The extent of this impairment correlates with HE severity as quantified by the CFF. The attenuation of the correlations after correction for attention deficits suggests a strong role of attention deficits for the impaired thermal perception. Thus, it provides initial evidence for a central impairment of thermal processing in HE due to alterations in high-level processes rather than due to peripheral neuropathic processes, which are a frequent complication in patients with liver cirrhosis.
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Affiliation(s)
- M. Brenner
- Medical Faculty; Institute of Clinical Neuroscience and Medical Psychology; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
- Department of Neurology; Medical Faculty; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - M. Butz
- Medical Faculty; Institute of Clinical Neuroscience and Medical Psychology; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - E. S. May
- Medical Faculty; Institute of Clinical Neuroscience and Medical Psychology; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - N. Kahlbrock
- Medical Faculty; Institute of Clinical Neuroscience and Medical Psychology; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - G. Kircheis
- Department of Gastroenterology, Hepatology and Infectious Disease; Medical Faculty; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - D. Häussinger
- Department of Gastroenterology, Hepatology and Infectious Disease; Medical Faculty; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
| | - A. Schnitzler
- Medical Faculty; Institute of Clinical Neuroscience and Medical Psychology; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
- Department of Neurology; Medical Faculty; Heinrich-Heine University Düsseldorf; Düsseldorf Germany
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Abstract
Minimal hepatic encephalopathy (mHE) is diagnosed in patients with severe liver disease but no clinical symptoms of encephalopathy if either neuropsychological or neurophysiological tests indicate cerebral dysfunction and other possible causes of brain dysfunction have been excluded. mHE is characterized by deficits in attention, visuospatial orientation, visuoconstructive abilities and motor function. Accordingly, mHE can be expected to interfere with a subject's working ability, especially in those occupations that require handiwork, and driving ability. Indeed, about 60% of blue-collar workers with mHE have been shown to be assessed as unfit for work compared to only 20% of white-collar workers, and about 50% of patients with mHE have been judged unfit to drive a car in several studies. mHE interferes with a patient's quality of life and is associated with an increased risk of developing overt HE as well as increased mortality. Whether mHE is of importance for cognitive function after liver transplantation has still to be clarified.
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May ES, Butz M, Kahlbrock N, Brenner M, Hoogenboom N, Kircheis G, Häussinger D, Schnitzler A. Hepatic encephalopathy is associated with slowed and delayed stimulus-associated somatosensory alpha activity. Clin Neurophysiol 2014; 125:2427-35. [DOI: 10.1016/j.clinph.2014.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 01/17/2014] [Accepted: 03/19/2014] [Indexed: 01/23/2023]
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Nabi E, Bajaj JS. Useful tests for hepatic encephalopathy in clinical practice. Curr Gastroenterol Rep 2014; 16:362. [PMID: 24357348 DOI: 10.1007/s11894-013-0362-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a serious complication of liver disease and portosystemic shunting that represents a continuum of neuropsychiatric changes and altered consciousness. It is classified as overt HE (OHE) when clinically apparent or as covert HE (CHE) in its mildest form. Progression of CHE to OHE and its impact of quality of life make its early diagnosis imperative. Several diagnostic techniques ranging from simple clinical scales to sophisticated computerized tests exist, yet diagnosis remains a challenge, due to the time, cost, and personnel involved. Psychometric tests appear promising due to their high sensitivity and low cost, but results are variable depending on age and education. The pros and cons of current diagnostic methods for OHE and CHE are reviewed, along with strategy for CHE testing.
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Affiliation(s)
- Eiman Nabi
- Department of Internal Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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Berlioux P, Robic MA, Poirson H, Métivier S, Otal P, Barret C, Lopez F, Péron JM, Vinel JP, Bureau C. Pre-transjugular intrahepatic portosystemic shunts (TIPS) prediction of post-TIPS overt hepatic encephalopathy: the critical flicker frequency is more accurate than psychometric tests. Hepatology 2014; 59:622-9. [PMID: 24620380 DOI: 10.1002/hep.26684] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
UNLABELLED Transjugular intrahepatic portosystemic shunts (TIPS) is a second-line treatment because of an increased incidence of overt hepatic encephalopathy (OHE). A better selection of patients to decrease this risk is needed and one promising approach could be the detection of minimal hepatic encephalopathy (MHE). The aim of the present prospective study was to determine whether pre-TIPS minimal hepatic encephalopathy was predictive of post-TIPS OHE and to compare Psychometric Hepatic Encephalopathy Sum Score(PHES) and the Critical Flicker Frequency (CFF) in this setting. From May 2008 to January 2011, 54 consecutive patients treated with TIPS were included. PHES and CFF were performed 1 to 7 days before and after TIPS at months 1, 3, 6, 9, and 12 or until liver transplantation or death. Before TIPS, MHE was detected by PHES and CFF in 33% and 39% of patients, respectively. After the TIPS procedure, 19 patients (35%) experienced a total of 64 episodes of OHE. OHE developed significantly more often inpatients for whom an indication for TIPS had been refractory ascites, with a history of OHE or of renal failure, lower hemoglobin level, or MHE as diagnosed by CFF. Post-TIPS OHE was more accurately predicted by CFF than by PHES. Absence of MHE at CFF had a good negative predictive value (91%) for the risk of post-TIPS recurrent OHE, defined as the occurrence of three or more episodes of OHE or of one episode which lasted more than 15 days. The absence of pre-TIPS history of OHE and a CFF value equal to or greater than 39 Hz had a 100% negative predictive value for post-TIPS recurrent OHE. CONCLUSION Aiming to decrease the rate of post-TIPS HE, the use of CFF could help selecting patients for TIPS.
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Affiliation(s)
- Pierre Berlioux
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Marie Angèle Robic
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Hélène Poirson
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Sophie Métivier
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Philippe Otal
- Service de radiologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier; Toulouse France
| | - Carine Barret
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Frédéric Lopez
- Plateforme de Protéomique I2MC Inserm Rangueil Toulouse; France
| | - Jean Marie Péron
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Jean Pierre Vinel
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
| | - Christophe Bureau
- Service d'hépato-gastro-entérologie CHU Toulouse Hopital Purpan et Université Paul Sabatier; Toulouse France
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Butz M, May ES, Häussinger D, Schnitzler A. The slowed brain: Cortical oscillatory activity in hepatic encephalopathy. Arch Biochem Biophys 2013; 536:197-203. [DOI: 10.1016/j.abb.2013.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/04/2013] [Accepted: 04/08/2013] [Indexed: 12/12/2022]
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Sakamoto M, Perry W, Hilsabeck RC, Barakat F, Hassanein T. Assessment and usefulness of clinical scales for semiquantification of overt hepatic encephalopathy. Clin Liver Dis 2012; 16:27-42. [PMID: 22321463 DOI: 10.1016/j.cld.2011.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) represents the effects of liver dysfunction on the brain. When HE is clinically obvious (eg, confusion, poor judgment, personality change), it is termed overt HE. The severity of HE is measured by different methods. Assessing the severity of HE is important for determining patient prognosis and effectiveness of therapy. This article discusses the different methods for grading HE, including clinical rating scales, neuropsychological tests, and neurophysiologic measures.
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Affiliation(s)
- Maiko Sakamoto
- Department of Psychiatry, University of California, San Diego, 220 Dickinson Street, Suite B (MC: 8231), San Diego, CA 92103, USA
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